Children's health staff shortages
Significant workforce shortages across multiple disciplines in children's health, impacting care delivery and patient safety.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
40 inquiry recs
12 PFD reports
43 committee recs
1 HSSIB rec
32 CQC actions
8 IMB recs
1 Scottish FAI
3 DHR recs
19 PHSO decisions
103 LGO/SPSO decisions
3 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(40)
185 — Sufficient qualified staff
Recommendation: Local authorities should give serious consideration to securing that there is a sufficient number of staff with the appropriate qualifications to deal with the growing burden of work of suspected child abuse (19.21).
Unknown
35 — Lists of psychiatrists and psychologists
Recommendation: Area Child Protection Committees should prepare lists of psychiatrists and psycholgists available to give professional advice when required (15.82).
Unknown
12 — Paediatric and perinatal pathologists
Recommendation: DHSC and NHS England must ensure that, by June 2033, there are 37 doctors in training posts as paediatric and perinatal pathologists, in line with the workforce requirement set out by the Royal College of Pathologists in the November 2025 …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor its …
Unknown
179 — Skilled staff in every department
Recommendation: No Social Work Department should be without a sufficient proportion of its staff adequately skilled and knowledgeable in the identification, investigation and management of problems of child protection (19.14).
Unknown
171 — More social work training facilities
Recommendation: An increase in the facilities for training in social work is required and in particular for specialist training over the whole area of child care (19.7).
Unknown
170 — Child protection as specialist area
Recommendation: The whole area of work in child protection requires to be seen as a specialist area to be undertaken by practitioners with specialist skills and knowledge with adequate training and support (19.5-6).
Unknown
102 — Lists of persons for medical examinations
Recommendation: Local authorities should prepare lists of appropriate persons to carry out medical examinations of children suspected of sexual abuse in so far as they have not already done so (17.39).
Unknown
BRIS-167 — Appoint National Director for Children's Healthcare Services to promote improvements
Recommendation: A National Director for Children’s Healthcare Services should be appointed to promote improvements in healthcare services provided for children.
Unknown
IHRD-85 — Deputy CMO for Children's Healthcare
Recommendation: The Department should appoint a Deputy Chief Medical Officer with specific responsibility for children's healthcare.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-71 — Children's Healthcare Governance
Recommendation: All Trust Boards should ensure that appropriate governance mechanisms are in place to assure the quality and safety of the healthcare services provided for children and young people.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-69 — Executive Director Responsibilities
Recommendation: Trusts should appoint and train Executive Directors with specific responsibility for: (i) Issues of Candour. (ii) Child Healthcare. (iii) Learning from SAI related patient deaths.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-61 — Paediatric Communication Training
Recommendation: Clinicians caring for children should be trained in effective communication with both parents and children.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-58 — Paediatric Fluid Management Training
Recommendation: HSC Trusts should ensure that all nurses caring for children have facilitated access to e-learning on paediatric fluid management and hyponatraemia.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
BRIS-198 — Urgently investigate paediatric cardiac surgery units for unsafe low patient volumes
Recommendation: An investigation should be conducted as a matter of urgency to ensure that PCS is not currently being carried out where the low volume of patients or other factors make it unsafe to perform such surgery.
Unknown
BRIS-197 — Centralise rare paediatric heart condition surgery to maximum two expert-validated units
Recommendation: Surgical services for children with very rare congenital heart conditions, such as Truncus Arteriosus, or involving procedures undertaken very rarely, should only be performed in a maximum of two units, validated as such on the advice of experts. Such arrangements …
Unknown
BRIS-196 — Mandate paediatric environment, trained staff, and PICU access for children's interventional procedures
Recommendation: The national standards should stipulate that children with CHD who undergo any form of interventional procedure must be cared for in a paediatric environment. This means that all healthcare professionals who care for these children must be trained and qualified …
Unknown
BRIS-195 — Require two paediatric surgeons performing 40-50 open-heart operations annually for infants
Recommendation: With regard to the very particular circumstances of open-heart surgery on very young children (including neo-nates and infants), we stipulate that the following standard should apply unless, within six months of the publication of this Report, this standard is varied …
Unknown
BRIS-194 — Establish minimum weekly operating sessions for paediatric cardiac surgeons to maintain competence
Recommendation: With regard to those surgeons who undertake paediatric cardiac surgery, although not stipulating the number of operating sessions sufficient to maintain competence, it may be that four sessions a week should be the minimum number required. Agreement on this should …
Unknown
BRIS-193 — Stipulate minimum paediatric cardiac surgery procedure volumes for hospitals to ensure outcomes
Recommendation: With regard to paediatric cardiac surgery, the standards should stipulate the minimum number of procedures which must be performed in a hospital over a given period of time in order to have the best opportunity of achieving good outcomes for …
Unknown
BRIS-192 — Develop national standards for all aspects of congenital heart disease care and treatment
Recommendation: National standards should be developed, as a matter of priority, for all aspects of the care and treatment of children with congenital heart disease (CHD). The standards should address diagnosis, surgical and other treatments, and continuing care. They should include …
Unknown
BRIS-186 — Require all surgeons operating on children to obtain paediatric qualification and revalidation
Recommendation: All surgeons who operate on children, including those who also operate on adults, must undergo training in the care of children and obtain a recognised professional qualification in the care of children. As matter of priority, the GMC, the body …
Unknown
BRIS-185 — Review and apply 1991 paediatric nurse staffing standards as minimum
Recommendation: The 1991 standards for the numbers of paediatrically qualified nurses required at any given time should serve as the minimum standard and should apply where children are treated (save in emergencies). The standards should be reviewed as a matter of …
Unknown
BRIS-184 — Ensure children are cared for in paediatric environments by qualified professionals
Recommendation: Children should always (save in exceptional circumstances, such as emergencies) be cared for in a paediatric environment, and always by healthcare professionals who hold a recognised qualification in caring for children. This is especially so in relation to paediatric intensive …
Unknown
BRIS-183 — Validate trusts providing children's acute services for child-centred policies, staff, and facilities
Recommendation: After completion of a pilot exercise, all trusts which provide acute hospital services for children should be subject to a process of validation to ensure that they have appropriate child- and family-centred policies, staff, and facilities to provide a good …
Unknown
BRIS-182 — Establish flexible Family Support Funds for travel costs at concentrated specialist children's trusts
Recommendation: Where specialist services for children are concentrated in a small number of trusts spread throughout England, these trusts should establish Family Support Funds to help families to meet the costs arising from travelling and staying away from home. The Funds …
Unknown
BRIS-181 — Organise children's specialist services for best staff, facilities, and outcomes, prioritising quality
Recommendation: Specialist services for children should be organised so as to provide the best available staff and facilities, thus providing the best possible opportunity for good outcomes. Advice should be sought from experts on the appropriate number of patients to be …
Unknown
BRIS-180 — Pilot children's hospitals running all acute and community services in a geographical area
Recommendation: Consideration should be given to piloting the introduction of a system whereby children’s hospitals take over the running of the children’s acute and community services throughout a geographical area, building on the example of the Philadelphia Children’s Hospital in the …
Unknown
BRIS-179 — Ensure free-standing children's hospitals provide access to all necessary facilities and specialists
Recommendation: In the case of existing free-standing children’s hospitals, particular attention must be given to ensuring that, through good management and organisation of care, children have access when needed to (a) facilities which may not routinely be found in a children’s …
Unknown
BRIS-178 — Locate children's acute hospital services in children's hospitals near general hospitals
Recommendation: Children’s acute hospital services should ideally be located in a children’s hospital, which should be physically as close as possible to an acute general hospital. This should be the preferred model for the future.
Unknown
BRIS-177 — NSF must provide strategic guidance for integrating children's healthcare services
Recommendation: There must be much greater integration of primary, community, acute and specialist healthcare for children. The NSF should include strategic guidance to health authorities and trusts so that services in the future are better integrated and organised around the needs …
Unknown
BRIS-176 — NSF must plan regular publication of children's healthcare quality and performance data
Recommendation: The NSF must include plans for the regular publication of information about the quality and performance of children’s healthcare services at national level, at the level of individual trusts, and of individual consultant units.
Unknown
BRIS-175 — NSF must include incentives for improving children's healthcare services, aiding needy trusts
Recommendation: The NSF should include incentives for the improvement of children’s healthcare services, with particular help being given to those trusts most in need.
Unknown
BRIS-174 — NSF must set obligatory and aspirational standards for children's services
Recommendation: The NSF should set obligatory standards which must be observed, as well as standards to which children’s services should aspire over time.
Unknown
BRIS-173 — NSF must establish standards for all children's acute healthcare services
Recommendation: The NSF should include a programme for the establishment of standards in all areas of children’s acute hospital and healthcare services.
Unknown
BRIS-172 — Urgently agree and implement National Service Framework for children's healthcare
Recommendation: The proposed National Service Framework (NSF) for children’s healthcare services must be agreed and implemented as a matter of urgency.
Unknown
BRIS-171 — Designate executive board member to protect children's interests in trusts
Recommendation: All trusts which provide services for children as well as adults, should have a designated executive member of the board whose responsibility it is to ensure that the interests of children are protected and that they are cared for in …
Unknown
BRIS-170 — Designate senior staff in health authorities for local children's healthcare commissioning
Recommendation: Each health authority and each primary care group or primary care trust should designate a senior member of staff who should have responsibility for commissioning children’s healthcare services locally.
Unknown
BRIS-169 — Expand Cabinet Committee remit to include healthcare for children and young people
Recommendation: The Cabinet Committee on Children and Young People’s Services should specifically include in its remit matters to do with healthcare and health services for children and young people.
Unknown
BRIS-168 — Consider creating a Children's Commissioner for England to promote children's rights
Recommendation: Consideration should be given to the creation of an office of Children’s Commissioner in England, with the role of promoting the rights of children in all areas of public policy and seeking improvements to the ways in which the needs …
Unknown
BRIS-139 — Include children's acute and paediatric cardiac services in discrete validation pilot
Recommendation: The pilot exercise for this form of validation should include children’s acute hospital services and paediatric cardiac surgery.
Unknown
Prevention of Future Deaths reports(12)
Jackson Chadd
Concerns: The coroner identified a lack of effective supervision for paediatricians, particularly during out-of-hours, and insufficient independent consultant assessment for paediatric admissions. Concerns also included the ineffective application of national guidelines for fever in children under one year and a failure to act on a parent's concerns.
Response (Frimley Park Hospital): • The Trust appointed a new Emergency Department Paediatric Consultant and established a consultant responsible for Paediatric A&E. • The Trust implemented a policy requiring junior doctors to notify a … (AI summary)
Response (Royal College of Paediatrics Child Health): • The Royal College of Paediatrics and Child Health (RCPCH) commenced a review of its 'Facing the Future' standards, specifically reconsidering the frequency of consultant review for admitted children. • … (AI summary)
Overdue
Helena Farrell
Concerns: Concerns were raised regarding an inadequate CAMHS referral system and staffing levels, alongside an unrealistic workload for the school nurse service. The coroner also noted unverified qualifications and professional registration for the school counsellor.
Response (Cumbria NHS Foundation Trust): • The Child and Adolescent Mental Health Service (CAMHS) referral system was redesigned, establishing a 48-hour response target for urgent referrals. • Staffing levels across CAMHS increased from 45 to … (AI summary)
Response (Cumbria County Council): • The Council funded three additional posts within the School Nursing Service and carried out a full case audit. • The Council is working to amend multiagency safeguarding systems and … (AI summary)
Responded
Emma Carpenter
Concerns: The coroner noted short-term funding for the specialist Eating Disorder Service and a national lack of inpatient beds for mentally ill children. Gaps were also identified in school nurses' attendance at Multi-Disciplinary Meetings due to funding, impacting communication with education staff.
Response (Department of Health): • The Department of Health provided £7 million to NHS England in 2014/15, which supported the commissioning of over 60 new CAMHS Tier 4 beds. • NHS England distributed £30 … (AI summary)
Response (NHS England): • NHS England is investing £30 million per year for Clinical Commissioning Groups to develop and deliver community eating disorder services. • Access and time standards for evidence-based eating disorder … (AI summary)
Response (Doncaster and Bassettlaw Hospitals NHS Trust): • The Trust formally communicated with Nottinghamshire Healthcare Foundation Trust to understand how to support patients from the Bassetlaw area. • The Trust offered a formal service level agreement and … (AI summary)
Responded
Robyn Skilton
Concerns: Insufficient resourcing and provision within mental health services for young people led to long waiting times for assessments by child psychiatrists, delaying diagnosis and treatment. The increased demand for CAMHS services without corresponding resource increases is noted as unsustainable.
Response (department of Health and Social Care): • The Department stated that the NHS Long Term Plan commits to investing an additional £2.3 billion annually into mental health services by 2023/24. • The Department reported an increase … (AI summary)
Responded
Alex Dews
Concerns: The coroner noted that the school did not refer a student to NHS mental health services due to perceived long waiting lists, instead providing privately procured support with an unclear allocation process. There was also no clear communication process between the school and the private provider.
Response (Outwood Grange Academies Trust): • The academy procured I-Space as an additional counselling service to address gaps in mental health provision. • I-Space now hosts a wellbeing drop-in session for students, including those awaiting … (AI summary)
Response (Department for Education): • The Department for Education outlined its existing statutory guidance and advice for schools regarding safeguarding and mental health provision, including expectations for working with external services and commissioning support. … (AI summary)
Response (Department of Health and Social Care): • The Department noted that the Department for Education and Outwood Grange Academies Trust had provided responses detailing actions to improve mental health support in schools. • The local NHS … (AI summary)
Responded
Madeleine Savory
Concerns: The coroner raised concerns about the national availability of Tier 4 beds in paediatric mental health facilities, impacting the timely allocation of care for children needing such services.
Response (NHS England): • NHS England has introduced NHS-Led Provider Collaboratives and invested funding to improve the availability of local inpatient (Tier 4) and alternative provision. • A review of the Children and … (AI summary)
Response (Department of Health and Social Care): • The Department supports NHS England’s approach to reduce reliance on inpatient mental health beds for children. • The Department supports the review and re-design of the model of provision … (AI summary)
Responded
Sailor Court
Concerns: The coroner noted unacceptably long waiting times for Child and Adolescent Mental Health Services (CAMHS) assessment and treatment, which have significantly increased. Concerns were also raised about the effectiveness of the 'Keeping in Touch' team due to insufficient resources to manage the growing waiting list.
Response (NHS England): • NHS England stated that significant additional funding, rising to over £900 million, was allocated to children and young people's mental health services in 2023/24. • The children and young … (AI summary)
Response (Department of Health and Social Care): • The Government stated it would recruit 8,500 additional staff across children’s and adult mental health services. • The Government stated it would introduce a specialist mental health professional in … (AI summary)
Responded
Aarav Chopra
Concerns: The coroner noted a lack of guidance for prophylactic antibiotics in immunocompromised patients and inadequate mechanisms for evidencing trainee experience, obtaining consent, or identifying and sharing individual patient risk factors.
Response (Birmingham Womens and Childrens NHS Foundation Trust): • The Trust is reviewing liver biopsy guidance for immunocompromised patients and strengthening processes for recording and sharing trainee competence information. • GMC consent guidance regarding trainee involvement will be … (AI summary)
Response (Department of Health and Social Care): • The Care Quality Commission has reviewed the death under its Specific Incident Guidance and is considering a criminal investigation. • Birmingham Women's and Children's NHS Foundation Trust is implementing … (AI summary)
Responded
Benjamin Arnold
Concerns: Concerns were raised regarding limited on-site paediatric and medical support at the SJUH maternity site and ambiguity in its operational classification. Additionally, the coroner noted a lack of standardised national guidelines for the LISA procedure.
Response (Resus Council UK): • Resuscitation Council UK (RCUK) provides national neonatal resuscitation courses that teach a standardised approach to resuscitation and stabilisation at birth. • RCUK’s Newborn Resuscitation Guidelines advise considering reversible factors … (AI summary)
Response (Yorkshire Humber Neonatal): • The ODN reviewed its regional guideline for Surfactant Administration for Respiratory Distress Syndrome and confirmed it addresses concerns regarding chest X-ray and consultant approval. • The ODN informed all … (AI summary)
Response (British Association of Perinatal Medicine): • The British Association of Perinatal Medicine (BAPM) referred to its existing frameworks for practice, including 'Managing the Difficult Airway in the Neonate,' 'Neonatal Airway Safety Standard,' and 'Consultant Working … (AI summary)
Response (Leeds Teaching Hospitals NHS Trust): • Staff at St James’s University Hospital have been reminded of the unit’s designation and the criteria it follows, with ongoing education and training planned. • An Executive-led group was … (AI summary)
Response (Royal College of Paediatrics and Child Health): • The Royal College of Paediatrics and Child Health stated it would discuss the matter of newborn cardiac arrest guidelines with the British Association of Perinatal Medicine. (AI summary)
Response (Department for Health and Social Care): • Officials made enquiries with NHS England to inform the Department's response. • The Department stated its expectation that Leeds Teaching Hospitals NHS Trust and other NHS Trusts would review … (AI summary)
Response (Resus Council UK): • The response included a Less Invasive Surfactant Administration (LISA) Checklist. • The checklist details required equipment, patient preparation, and team roles for the LISA procedure. • The checklist provides … (AI summary)
Responded
Imogen Nunn Prevention of future deaths report
Concerns: The coroner identified a national shortage of British Sign Language (BSL) interpreters and BSL-proficient clinicians, impacting mental health support for Deaf patients, and noted the absence of statutory regulation for BSL interpreters.
Response (Department for Education): • The Department for Education is introducing a GCSE in British Sign Language, with assessment rules established by Ofqual. • Officials will be asked to consider changes to enable more … (AI summary)
Overdue
Ellame Ford-Dunn Prevention of future deaths report
Concerns: The coroner noted insufficient Tier 4 Paediatric Mental Health beds and an average 8-day wait. Children needing mental health care are accommodated on acute paediatric wards not designed or staffed for their needs, lacking community care or specialist beds.
Response (NHS England): • NHS England published a framework in 2022 to support acute paediatric settings in providing care for children with mental health needs and launched a digital platform for staff training. … (AI summary)
Responded
Aylina Akhmadova
Concerns: The coroner noted that safety netting advice for 999 calls needs to clarify interpreter availability for ambulance triage. Concerns were raised about the risks of using informal interpreters in primary care, which can lead to misunderstandings about accessing emergency assistance.
Response (Royal College of General Practitioners): The RCGP explains that the death occurred before the child had GP contact, limiting its direct influence, and that the processes of other organisations (midwives, health visitors) are beyond its … (AI summary)
Response (Institute of Health Visiting): The Institute of Health Visiting has developed web-based parent-facing resources on childhood illnesses, translatable into 39 languages. They will disseminate learning from this report, continue promoting professional development on culturally … (AI summary)
Response (Royal College of Midwives): The Royal College of Midwives (RCM) explained its role as a professional association and trade union, stating it lacks authority to implement service-level changes. It highlighted existing RCM positions, tools … (AI summary)
Responded
Select committee recommendations(43)
#14 —
Recommendation: In addition, it is paramount that a plan is implemented to increase the size and wellbeing of the children and young people’s mental health workforce based on independently verified estimates of the number of people needed in different disciplines and …
Response attribution not verified
#13 —
Recommendation: One of the largest barriers to increasing access to mental health provision for children and young people remains the size of the mental health workforce. We have seen that children and young people’s mental health practitioners face staff shortages, increasing …
Response attribution not verified
#4 — Require DHSC to detail ICB SEN prioritisation, workforce plans, and targets for reducing waiting lists.
Recommendation: Accessing health expertise presents a significant barrier to identifying and supporting SEN needs. DHSC plays a critical role in the SEN system. It jointly published with DfE the Code of Practice and 2023 improvement plan and is responsible for overseeing …
Response attribution not verified
#67 — Develop joint SEND workforce plan to address shortages and re-deploy professionals therapeutically
Recommendation: The DfE and DHSC should urgently develop a joint SEND workforce plan to address shortages and build capacity across education, health, and care services. This should include explicit measures to deliver a shift in the deployment of educational psychologists, speech …
Response attribution not verified
#66 — Shortages of educational psychologists and allied health professionals undermine quality of SEND support
Recommendation: Shortages of educational psychologists and allied health professionals, including speech and language therapists, occupational therapists, and physiotherapists are significantly undermining the availability and quality of SEND support. These workforce gaps delay assessments, restrict access to essential interventions, and place additional …
Response attribution not verified
#15 — Set plans to support non-NHS children's health professionals and review multidisciplinary team guidance.
Recommendation: Many professions which play a key role in delivering children’s health care are not entirely or primarily employed by the NHS. We recommend the Government sets out how it plans to support those professions in non- NHS settings, particularly allied …
Response attribution not verified
#14 — Create sustainable children's health workforce with specific recruitment targets in the NHS Plan.
Recommendation: The Government must take the opportunity presented by the forthcoming NHS 10 Year Workforce Plan to create a sustainable and well-resourced children’s health workforce. While we understand the Government’s desire for the workforce plan to go beyond numbers, a plan …
Response attribution not verified
#13 — Significant shortages across children's health workforce are impacting care delivery and patient safety.
Recommendation: Throughout this inquiry we heard that the children’s health workforce is being stretched to breaking point. There are significant shortages across multiple disciplines which prevent professionals from delivering the care young children and their families need and that, in some …
Response attribution not verified
#9 — Create plan to rebuild health visitor workforce and recruit at least 1000 additional staff.
Recommendation: The Government must create a specific plan to rebuild the health visitor workforce in its forthcoming NHS Long Term Workforce Plan. This plan must be informed by safe staffing tools to ensure that health visitors have a manageable workload. As …
Response attribution not verified
#8 — Decimated health visitor workforce threatens government ambition for children's early life outcomes.
Recommendation: The Government will fail to deliver on its ambition to give every child the best start in life unless it takes urgent action to rebuild the health visitor workforce, which has been decimated over the last 10 years. (Conclusion, Paragraph …
Response attribution not verified
#17 —
Recommendation: In 2021, a NHS survey showed nearly 1 in 5 of 6- to 16-year-olds in England had a probable mental health disorder. The survey also found that almost 40% had experienced a deterioration in mental health since 2017 and 13.5% …
Response attribution not verified
#9 —
Recommendation: The renewed Women’s Health Strategy should include an aim to improve the provision of school nurses, particularly in more deprived areas, where need is often greatest. Improving early access to care reduces the risk of symptoms worsening and the increased …
Response attribution not verified
#8 —
Recommendation: School nurses can play a crucial role in helping girls recognise menstrual problems and provide a necessary, early pathway to appropriate care. However, the school nurse system has seen a substantial overall reduction in funding over many years and is …
Response attribution not verified
#4 — Clarify required family court capacity and plans to resolve judge and social worker shortages.
Recommendation: Shortages in the number of district judges and social workers are contributing to delays, and to significant regional differences in timeliness of resolving cases. There are wide variations in durations of cases; for example, in December 2024, the average duration …
Response attribution not verified
#6 — Set out plan for effective deployment of skilled professionals in inclusive mainstream education.
Recommendation: As part of delivering a fully inclusive mainstream, the Government must set out how it will deliver, over time, a system in which highly skilled professionals, including educational psychologists and speech and language therapists, are less tied up in undertaking …
Response attribution not verified
#41 —
Recommendation: We have heard evidence about the inadequate provision of mental health support and care in social care settings, which can be one of the contributing causes for self-inflicted injuries and deaths. The government must tackle this as a matter of …
Response status not verified
#38 —
Recommendation: We have seen evidence that children in need, a group that includes children in care and disabled children, are four times more likely to die due to deliberately inflicted injury, abuse or neglect than children without any social care involvement. …
Response status not verified
#8 —
Recommendation: The Government must develop a more rounded view of what children need and what positive outcomes for children are as we recover from the pandemic. Specifically, with regard to mental health, we believe that the Department must fast-track its commitments …
Response attribution not verified
#19 —
Recommendation: The Department for Education also spoke about an NHS England consultation, which closed early in 2022, on introducing waiting time standards for community and A&E mental health care.48 The new standards would comprise a 24-hour standard for urgent community mental …
Response attribution not verified
#5 —
Recommendation: We are extremely concerned about the waiting time for children to receive support for mental health issues and about the proportion of adolescent girls seeking help. A survey found nearly 1 in 5 of 6- to 16-year-olds in England had …
Response attribution not verified
#16 —
Recommendation: We agree that catch up funding should be weighted towards children who have been “hardest hit” by disruption to their education. We know that many children with special educational needs and disabilities (SEND) will be in the hardest hit group; …
Response attribution not verified
#7 —
Recommendation: Schools have an important role in how well disadvantaged White children recover from the pandemic. This relates to academic progress, emotional development, and good mental health. This is as true for disadvantaged White pupils as it is for other groups, …
Response attribution not verified
#2 —
Recommendation: With 8 out of 10 midwives reporting that they did not have enough staff on their shift to provide a safe service, it is clear that urgent action is needed to address staffing shortfalls in maternity services. Evidence submitted to …
Response attribution not verified
#18 —
Recommendation: We asked the Department for Education what it considers it can do to support young girls with their mental health. It told us that it ensures the work it does with the Department of Health and Social Care is built …
Response attribution not verified
#8 —
Recommendation: In order to support parents who have missed health visiting checks, we recommend that the Government provide additional funding to local authorities to enable in- person visits to new parents by appropriate local authority, voluntary organisation, or health visiting staff, …
Response attribution not verified
#17 — Delays in establishing SEND national standards attributed to co-creation and specific priority areas.
Recommendation: We asked the Department why the process was taking so long and specifically why it was not expecting to have a full set of new national standards even by the end of 2025. The Department said that it had made …
Response attribution not verified
#16 — Department's SEND improvement plan faces significant delays, extending national implementation beyond 2025.
Recommendation: We have been regularly pressing the Department to improve its support for pupils with special educational needs and disabilities (SEND) since we reported on this subject in May 2020.31 The Department finally published the results of its SEND review in …
Response attribution not verified
#51 —
Recommendation: The multiagency rapid needs assessment published in January 2021 noted there were no health services in the areas of Southern Tigray affected by the conflict, meaning that regular health service activities such as Maternal and Child Health, treatment of endemic …
Response attribution not verified
#37 —
Recommendation: We recommend that the Department implement a new system of early intervention to support children and young people who self-harm and are at risk of committing suicide. Educational settings, as a universal provision, can have an important role to provide …
Response attribution not verified
#5 —
Recommendation: The Department of Health and Social Care—in partnership with the Department for Education and all other relevant Government departments—must take radical steps to shift the focus in mental health provision towards early intervention and prevention. This must ensure that all …
Response attribution not verified
#4 —
Recommendation: During the pandemic, children and young people’s mental health has significantly worsened and the scale of the backlog mean that the NHS will not be able to treat its way out of this crisis. The need for early intervention and …
Response attribution not verified
#19 —
Recommendation: Throughout our inquiry, we have heard that pupils’ wellbeing and mental health have been one of the greatest challenges as schools return. All pupils should undergo a mental health and wellbeing assessment to understand the scale of the problem and …
Response attribution not verified
#18 —
Recommendation: The Department must fast-track its commitments to ensuring all schools have a designated mental health lead. All catch-up plans, including enrichment activities and longer school days, must include a specific role for activities that focus on mental health and wellbeing.
Response attribution not verified
#17 —
Recommendation: Before the pandemic there were serious concerns about the mental health of our children and young people. The pandemic has exacerbated an existing crisis in mental health, with as many as 1 in 6 children aged 6–16 years old now …
Response attribution not verified
#2 —
Recommendation: The Department must continue to establish the full effect of the pandemic on children and young people. This must consider the impacts felt by children from disadvantaged backgrounds and on the regional disparities of support offered. This must not be …
Response attribution not verified
#7 —
Recommendation: We remain concerned at the number of new parents reporting limited or no access to health visiting services over the period of the pandemic. Virtual checks were a necessary innovation during covid-19, but new parents and their children must now …
Response attribution not verified
#10 — Department's strategy risks a decade to return disadvantage gap to pre-pandemic levels.
Recommendation: We pressed the Department on when it hoped to eliminate the disadvantage gap completely. It told us that no country in the world had completely eliminated its 10 ERS0003 The Children and Young People’s Mental Health Coalition page 1; ERS0005 …
Response attribution not verified
#6 — COVID-19 pandemic severely impacted young people's mental health, necessitating whole-school approach
Recommendation: Evidence submissions from the Children and Young People’s Mental Health Coalition, Young Minds and Adoption UK highlighted the impact that the COVID-19 pandemic had had on young people’s mental health.10 The Department agreed with Young Minds’ recommendation calling for a …
Response attribution not verified
#9 — Calculate minimum ODA for training health personnel and invest in health infrastructure in LMICs
Recommendation: The involvement of trained health personnel and access to adequate health care facilities for maternal and newborn health improves health outcomes for the mother and child. The FCDO should support the strengthening of healthcare systems by prioritising investment in the …
Response attribution not verified
#2 — Require Northern Ireland Executive to prioritise SEN pupil numbers in education funding allocation.
Recommendation: After years of under-investment, the education sector has been struggling to fulfil its statutory duties. Spending per pupil has been consistently lower in Northern Ireland than in England. We are particularly concerned about the future of provision for children and …
Response attribution not verified
#36 —
Recommendation: We are deeply concerned about the increasing numbers of children and young people who experience self-harm and suicide and the quality of care they are able to access. Much more needs to be done to tackle suicide and self-harm amongst …
Response attribution not verified
#7 —
Recommendation: Commitments in the 2017 Green Paper and the NHS Long Term Plan have been taken seriously by NHS England and led to a significant expansion of provision. We are, however, concerned that many commitments may not yet be ambitious enough …
Response attribution not verified
#20 —
Recommendation: Ahead of the 2021 Spending Review, we recommend that the Government assess which elements of the Best Start for Life Review’s implementation could be accelerated—in particular, opportunities to grow the health visiting workforce—and provide targeted funding to help achieve this.
Response attribution not verified
HSSIB safety recommendations(1)
CQC inspection actions(32)
William Harvey Hospital
The trust should ensure a suitable paediatric trained physiotherapist is available for children. 9(1): Person-centred care.
Should Do
Westmorland General Hospital
The trust must review the service’s paediatric staffing provision, including the environment they wait in and the paediatric nursing and medical cover in line with The Royal College of Paediatrics and Child Health (RCPCH) Standards for Children and Young People …
Must Do
Westmorland General Hospital
The service must ensure that there is enough staff with the right qualifications, skills, training and experience to provide care and treatment, specifically in relation to medical staffing including taking into account national guidance for the care of children and …
Must Do
The York Hospital
The trust should consider recruiting looked after children specialist nurses to support capacity for initial health reviews.
Should Do
Scarborough Hospital
The trust should consider recruiting looked after children specialist nurses to support capacity for initial health reviews.
Should Do
Pilgrim Hospital
The trust should ensure the, paediatric area within the Emergency Department, nursing and medical staffing requirements meet the Royal College of Paediatrics and Child Health (RCPCH).
Should Do
Pilgrim Hospital
The trust should ensure, the paediatric area within the Emergency Department, nursing and medical staffing requirements meet the Royal College of Paediatrics and Child Health (RCPCH).
Should Do
Kettering General Hospital
The service should continue its recruitment campaign to increase the number of registered children's nurses it employs.
Should Do
Kettering General Hospital
The servicemust ensure there are enough nursing staff to ensure safe staffing levels are maintained across the service in line with establishment reviews, trust policy and staffing requirements which meet the Royal College of Paediatrics and Child Health standards. This …
Must Do
Clatterbridge Hospital
The services should continue with plans to recruit additional play specialists to increase the establishment within the service.
Should Do
St Benedict's Hospice
The service must ensure they meet national standards for paediatric medical staffing.
Must Do
St Benedict's Hospice
The service must ensure they meet national standards for paediatric nurse staffing.
Must Do
Victoria Infirmary
The service should continue with improvement plans to address staffing shortfalls in children’s occupational therapy services.
Should Do
Victoria Infirmary
The service must ensure that they have enough staff with the right qualifications, skills, training and experience to provide care and treatment to children and that staffing of children’s nurses is in line with national guidance.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure they meet national standards for paediatric medical staffing.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure they meet national standards for paediatric nurse staffing.
Must Do
Pilgrim Hospital
The trust should consider routine monitoring or auditing of waiting times for children to have a medical review as per the Royal College of Paediatrics and Child Health (RCPCH).
Should Do
Kettering General Hospital
The servicemust ensure people have timely access to services such as first definitive tretament for paediatric services and promptly receive the right treatment in line with national guidance.
Must Do
Diana Princess of Wales Hospital
The service must continue to appropriately recruit staff (specifically registered sick children’s nurses (RSCN) and ensure that there are sufficiently suitably qualified, competent and experienced staff on duty to meet the needs of patients. The emergency department was not meeting …
Must Do
St Benedict's Hospice
The service should review the resources available for the occupational therapy department and explore options for improving the environment at Palmer Community Hospital to ensure they meet the needs of children accessing the service.
Should Do
St Benedict's Hospice
The service should continue with the plans of monitoring caseloads and introducing additional management support to ensure the 0-19 service improves the compliance with the developmental reviews for children.
Should Do
Durham Diagnostics and Treatment Centre
The service should review the resources available for the occupational therapy department and explore options for improving the environment at Palmer Community Hospital to ensure they meet the needs of children accessing the service.
Should Do
Bridlington Hospital
The service must ensure it has enough, suitably qualified, competent and experienced medical and nursing staff in its urgent and emergency care service at Scarborough hospital, to meet the RCEM recommendations, including enough staff who are able to treat children …
Must Do
Bridlington Hospital
The service must ensure all medical and nursing staff in urgent and emergency care services at Scarborough hospital complete the required specialist paediatric life support training to enable them to safely care for children in the department.
Must Do
William Harvey Hospital
The trust must ensure all relevant staff are trained to the highest level of life support. This includes ensuring the Childrens Assessment Unit has a staff member on duty trained in Advanced Paediatric Life Support in line with the Royal …
Must Do
Royal Victoria Infirmary
The service should consider a review of staffing on the Paediatric Intensive Care Unit to ensure that the skill mix supports the acuity of patients.
Should Do
Durham Diagnostics and Treatment Centre
The service should continue with the plans of monitoring caseloads and introducing additional management support to ensure the 0-19 service improves the compliance with the developmental reviews for children.
Should Do
Durham Diagnostics and Treatment Centre
The service must ensure that staff caring for children and young people have completed training/competencies to enable them to care for children and young people.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure that staff are appropriately trained in caring for children and young people with mental health conditions.
Must Do
Clifton Hospital
The trust should consider acting to improve breastfeeding rates and improve breastfeeding support in line with the Baby Friendly Initiative scheme.
Should Do
Clifton Hospital
The trust should ensure it reviews theatre provision for children and young people.
Should Do
Bridlington Hospital
The service should consider having a designated paediatric area within the first assessment and major’s areas of its urgent and emergency care service at Scarborough hospital.
Should Do
IMB individual recommendations(8)
Wandsworth (2022)
The prison has significant staffing problems which were adversely affecting the regime. While the prison may theoretically have a full complement of staff, between 30% and 40% were either absent or on restricted duties. Will the Minister provide senior management with the resources and support to address this issue?
Ministry of Justice
In Progress
Swaleside (2022)
The Board is extremely concerned at the continuing low numbers of staff and the seeming inability to recruit. The inequality of pay and conditions when compared to other government agencies is certainly a factor in the cause of this issue together with the accessibility of the geographical area in which the prison is situated. The low numbers of staff severely …
HMPPS
In Progress
Isle of Wight (2022)
This was another difficult year with the prison continuing to face Covid challenges while managing an increasing population of Category C prisoners. Welcome progress was made towards a more normal regime as Covid restrictions were relaxed. However, the anticipated benefits of this were severely limited by chronic staff shortages. This resulted in prisoners remaining locked up for considerable periods of …
Other
Cookham Wood (2020)
There is a chronic lack of secure mental health hospital beds for children nationally, and the time taken to transfer boys with significant mental health issues to hospital from a YOI is inhumane. What urgent steps will be taken to work with ministerial colleagues in the Department of Health to provide more secure mental health services for children?
Ministry of Justice
In Progress
Feltham (2020)
Will the cap on admissions of young people to Feltham A be made permanent, and good levels of staffing be maintained?
Other
In Progress
Humber (2021)
Key workers: While we understand that the effectiveness of the key worker process has been compromised due to the Covid-19 restrictions and staff shortages, we would urge the Governor to make it a high priority to re-establish this excellent initiative as soon as possible.
Governor / Director
Cookham Wood (2021)
What urgent steps will be taken to work with ministerial colleagues in the Department of Health to provide more secure mental health services for children?
Ministry of Justice
In Progress
Bronzefield (2023)
The Board has noted that there has been a severe and sustained shortage of staff provided by The Forward Trust for recovery services. How does NHS England plan to address this issue as a matter of urgency?
NHS / Healthcare Provider
Health investigations(10)
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 7
Consultant Oversight: Explore a national workforce plan to support sustainable consultant-led oversight, including realistic weekend cover models in paediatrics.
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 19
NHS England Regional Team, NHS North East and North Cumbria Integrated Care Board and the CQC must consider the impact and risks on Tier 4 CAMHS if a local Safeguarding Board is found to be weak or inadequate, or a local provider is found to have a major staffing issue.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Mark Blackston, Northfleet, Kent — Rec 2.5.25
Work in Kent and Medway on the commissioning of specialist (Tier 4) CAMHS should specifically identify the needs of young people with mental health problems who present a risk to others, identify the range of provision required to meet those needs, identify gaps in provision and plan, if necessary on …
south_east
Independent investigation: Harry Upton, Culcheth, Warrington (2002) — Rec 9.1
The Trust should consider the delivery of a more responsive CAMH Service to patient’s such as DC. The RCA team recommends that a review is conducted by the Trust of the demands and resources within CAMHS to ensure they are meeting the requirements of service users and other clinicians. In …
north_west
An independent investigation into the care and treatment of Jack … — Rec 1
RDaSH should introduce either training and/or a mentoring programme for their adult mental health practitioners who are required to undertake out-of-hour assessments of young people in Accident and Emergency Departments, to ensure they have the required skills, competencies and knowledge base to undertake assessments of the needs and risks of …
Rotherham Doncaster and South Humber NHS Foundation Trust
north_east_yorkshire
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 6
The panel recommends that all those involved in the Statutory provision of Child and Adolescent Mental Health (CAMH) services consider whether section 31 of the Health Act 1999 would help improve the services they offer, or whether some other form of formalised integration would be beneficial. Such integration should include …
south_east
An independent investigation into the care and treatment of a … — Rec 6
A service should be agreed regarding Autism Spectrum Disorder provision in CAMHS between SaBP and Commissioners.
south_east
An independent investigation into the care and treatment of Emily … — Rec 9
NHS England Specialised Commissioning and the North East region Integrated Care Systems (ICSs), as system leaders, should work with the Directors of Children’s Services in the North East region to commission services that will meet the needs of the small but growing number of young people with complex needs and …
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 14
NHS North East and North Cumbria (NENC) Integrated Care Board, as system leaders, should work with the Directors of Children’s Services North East region to commission services that will meet the needs of the small but growing number of young people with complex needs and challenging behaviours that have both …
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation: Leonne Weeks, Dinnington (2017) — Rec 1
RDaSH should introduce either training and/or a mentoring programme for their adult mental health practitioners who are required to undertake out-of-hour assessments of young people in Accident and Emergency Departments, to ensure they have the required skills, competencies and knowledge base to undertake assessments of the needs and risks of …
north_east_yorkshire
Independent reviews(6)
Laming Review (Baby P) — Rec 32
The Department of Health should prioritise its commitment to promote the recruitment and professional development of health visitors (made in Healthy lives, brighter futures) by publishing a national strategy to support and challenge Strategic Health Authorities to have a sufficient capacity of well trained health visitors in each area with …
Other
Allen Early Intervention Review (Part 1) — Rec 16
I recommend that we improve workforce capability of those working with the 0–5s. We should: • increase graduate-led, or even postgraduate, pre-school leadership; • ensure that all early years settings employ someone with Early Years Professional Status (EYPS) on site; and • establish a Workforce Development strategy led by the …
Other
Cass Review — Rec 14
NHS England, through its Workforce Training and Education function, must ensure requirements for this service area are built into overall workforce planning for adolescent services.
Health & Social Care
Accepted
Darzi Review — Rec 7
Waiting lists for community services and mental health have surged. As of June 2024, more than 1 million people were waiting for community services, including more than 50,000 people who had been waiting for over a year, 80 per cent of whom are children and young people. By April 2024, …
Health & Social Care
Cass Review — Rec 4
When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
Health & Social Care
Accepted
Mental Health Taskforce 2016 — Rec 1
NHS England should continue to work with Health Education England (HEE), Public Health England (PHE), Government and other key partners to resource and implement Future in Mind, building on the 2015/16 Local Transformation Plans and going further to drive system-wide transformation of the local offer to children and young people …
Health & Social Care
PHSO casework decisions(19)
P-001525 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Miss E complained CAMHS failed to provide timely autism/ADHD assessment or alternative treatment for her daughter, causing significant family distress.
NHS in England
Sep 2022
P-004748 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs E complained about delays in diagnosing her son with autism, and the lack of follow up care, impacting his school attendance and mental health.
NHS in England
Jan 2026
P-004670 — West Suffolk NHS Foundation Trust
Mrs J complained the Trust incorrectly arranged her son K's autism assessment, failed to refer him for a second opinion, and provided incorrect referral information, leaving him without support.
NHS in England
Jan 2026
P-001840 — Cornwall Partnership NHS Foundation Trust
Mrs H complained about delays in her son's autism assessment and Child and Adolescent Mental Health Services' (CAMHS) refusal to assess him, leading to a lack of support.
NHS in England
Jan 2023
P-003835 — Sussex Partnership NHS Foundation Trust
Mrs B complained CAMHS failed to provide appropriate one-to-one therapy for her daughter, delayed medication, and did not monitor her physical health despite self-harm and low weight.
NHS in England
Jul 2023
P-003855 — East London NHS Foundation Trust
Mr A complained the Trust stopped his daughter's autism assessment and family support without explanation, causing his family uncertainty, anxiety, and distress.
NHS in England
Jul 2023
P-003489 — Humber Teaching Hospitals NHS Foundation Trust
Mrs H complained the Trust significantly delayed offering treatment and support, and arranging a specialist psychiatrist, for her son following his ADHD and autism diagnosis, leaving him unsafe.
NHS in England
Apr 2025
P-003806 — County Durham and Darlington NHS Foundation Trust
Ms M complained the Trust delayed a referral and funding application for her son to see an eating specialist, causing significant distress and a long-term detrimental impact.
NHS in England
Partly Upheld
Aug 2025
P-004327 — Hampshire and Isle of Wight Healthcare NHS Foundation …
Miss A complained about CAMHS and a residential facility's lack of support, misdiagnosis, and failure to make reasonable adjustments for her daughter, leading to severe health and family impact.
NHS in England
Nov 2025
P-004663 — Hampshire Hospitals NHS Foundation Trust
Ms A complained the Trust failed to correctly assess her son for ASD and later refused a second assessment, causing him prolonged distress and missing SEN school opportunity.
NHS in England
Not Upheld
Jan 2026
P-001167 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mrs L complained two Trusts failed to diagnose her daughter's ASD, preventing school support and causing emotional distress, weight loss, and incorrect medication.
NHS in England
Not Upheld
Oct 2021
P-001896 — Manchester University NHS Foundation Trust
Miss and Mrs B complained CAMHS delayed diagnosing Miss B with disruptive mood dysregulation disorder, and inadequately explained a referral, causing distress, educational setbacks, and family impact.
NHS in England
Upheld
Mar 2023
P-004335 — Essex Partnership University NHS Foundation Trust
Miss O complained PCS and EPUT failed to accept her daughter's ADHD/ASD referral and inappropriately used medical records to decline it. This impacted her daughter's support and mental health.
NHS in England
Nov 2025
P-004357 — Hampshire and Isle of Wight Integrated Care Board
The ICB wrongly found her son ineligible for care and withdrew provision, failing to take a holistic view of his complex needs.
NHS in England
Partly Upheld
Nov 2025
P-004358 — Midlands Partnership University NHS Foundation Trust
The Trust wrongly blamed Miss K's mental health for A's difficulties and refused autism assessment (2014-2018), causing distress and delayed support.
NHS in England
Nov 2025
P-004359 — Midlands Partnership University NHS Foundation Trust
The Trust refused to acknowledge B's severe developmental delays or assess for autism (2018-2019), leading to distress and a delayed diagnosis.
NHS in England
Nov 2025
P-001501 — Tees, Esk and Wear Valleys NHS Foundation Trust
Miss E complained the Trust failed to put her son on the ADHD pathway after she declined a course, causing distress and delays in his care.
NHS in England
Aug 2022
P-001837 — HCRG Care Group
Miss Z complained her son was denied a face-to-face GP appointment and referral, and a consultant inappropriately cancelled his autism assessment.
NHS in England
Dec 2022
P-002406 — A practice in the West Northamptonshire area
Miss L complained a practice in Northamptonshire failed to give blood test results, delayed diagnosing her daughter's thyroid issues, and missed treatment opportunities.
NHS in England
Jan 2024
LGO / SPSO decisions(103)
PSOW-201903330 — Cwm Taf Morgannwg University Health Board
Ms C complained about her daughter, H’s, management and care by Cwm Taf Morgannwg University Health Board’s “(the First Health Board’s”) Child and Adolescent Mental Health Services (“CAMHS”), including what Ms C felt was an unreasonable delay in diagnosing her daughter’s Borderline Personality Disorder (“BPD”). Ms C also complained about …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
PSOW-202503182 — Powys Teaching Health Board
Ms A complained that Powys Teaching Health Board assessed and then discharged her son from the neurodevelopment pathway. She also said that the Health Board did not respond to all of the concerns raised in her initial complaint. Whilst the Ombudsman noted that Ms A’s son had initially been discharged …
PSOW (Public Services Om…
Health
Sep 2025
20-009-234 — London Borough of Wandsworth
Summary: Mrs X complains about the Council’s handling of her requests for more support for her child since 2018 and her complaints about this. The Council has already addressed and remedied faults identified by considering Mrs X’s complaints through all three stages of the statutory complaint process twice. The Council …
LGO (Local Government & …
Children S Care Services
Upheld
Jan 2022
21-016-344 — Suffolk County Council
Summary: there was delay by the Council arranging Speech and Language Therapy for Mr F’s daughter, G, but the Council has offered an appropriate remedy. There are no grounds for the Ombudsman to recommend the Council refund Mr F’s legal expenses.
LGO (Local Government & …
Education
Upheld
Jun 2022
24-022-535 — Gloucestershire County Council
Summary: We will not investigate this complaint that the Council delayed carrying out an Education, Health and Care needs assessment. The Council has accepted there were delays connected with a shortage of educational psychologists. It has now agreed to suitable remedies.
LGO (Local Government & …
Education
Upheld
Jul 2025
PSOW-202006042 — Aneurin Bevan University Health Board
Mr A complained that Aneurin Bevan University Health Board failed to diagnose his daughter, B, with Attention Deficit Hyperactivity Disorder (“ADHD” – a condition that affects a person’s behaviour in terms of inattention and/or hyperactivity and impulsivity)in a timely manner as the 2 referrals that were made to the Integrated …
PSOW (Public Services Om…
Health
Upheld
Aug 2022
20-014-415 — Wiltshire Council
Summary: Mr X complains the Council, the police and his child’s school failed to properly deal with his safeguarding concerns about his child’s welfare. Mr X says the matter has caused him significant distress, financial loss and his child continues to be at risk of significant harm. There is no …
LGO (Local Government & …
Children S Care Services
Not Upheld
Jan 2022
20-008-890 — Birmingham City Council
Summary: We will not investigate this complaint about the Council’s action concerning Mrs X’s grandchildren. The contact and residence of children has been and can only be decided by a court. Matters from 2019 or earlier are late and there is no good reason to exercise discretion to investigate them …
LGO (Local Government & …
Children S Care Services
Jan 2022
20-007-078 — Worcestershire County Council
Summary: Mrs B complained that the Council acted inappropriately by telling her former foster children’s birth family that it was concerned she may attend their mother’s funeral despite there being no grounds to reach this conclusion. The Ombudsman found no grounds to criticise the Council.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jan 2022
21-013-085 — Coventry City Council
Summary: We will not investigate this complaint about how the Council dealt with a safeguarding referral in 2014. This is because this happened too long ago, and I see no reason why the complaint could not have been pursued with the Ombudsman sooner.
LGO (Local Government & …
Children S Care Services
Jan 2022
21-013-008 — London Borough of Richmond upon Thames
Summary: We will not investigate this complaint about complaint handling. There is not enough evidence of fault to warrant this.
LGO (Local Government & …
Children S Care Services
Jan 2022
21-013-461 — North Northamptonshire Council
Summary: We cannot investigate this complaint about the Council’s actions in removing Miss X’s baby. The complaint is not separable from matters that have been subject to court proceedings.
LGO (Local Government & …
Children S Care Services
Jan 2022
22-003-665 — Middlesbrough Borough Council
Summary: We cannot investigate this complaint about the Council’s actions. The matters complained of are not separable from matters concerning the residence of and contact with Mr X’s child. This has been subject to court proceedings and Mr X also has a right to return to court it would be …
LGO (Local Government & …
Children S Care Services
Jun 2022
23-010-248 — Cheshire East Council
Summary: Mrs X complained the Council did not review her child’s education, health and care plan within the statutory timescales, failed to provide the provision in the plan and failed to provide alternative education when her child was out of school. We found fault by the Council causing Mrs X …
LGO (Local Government & …
Education
Upheld
Jun 2024
23-009-667 — Wiltshire Council
Summary: Miss X complained the Council has failed to provide wraparound or holiday childcare for children with special educational needs in the county. We found evidence of fault by the Council because it failed to make sure it was aware of the childcare needs of parents with children who have …
LGO (Local Government & …
Education
Upheld
Jun 2024
24-000-963 — London Borough of Bromley
Summary: Ms A complained the Council has declined a mediation meeting about its decision not to assess her child for an Education, Health and Care Plan. We discontinued our investigation as we cannot investigate the Council’s decision as it is caught by Ms A’s appeal to the Tribunal, which the …
LGO (Local Government & …
Education
Not Upheld
Sep 2024
24-000-474 — Somerset Council
Summary: Miss X complained that the Council had failed to consider a funding request from her son’s school. She said the Council had failed to stick to deadlines and her son has been out of education. We find the Council was at fault. This cause significant distress to Miss X …
LGO (Local Government & …
Education
Upheld
Sep 2024
24-007-018 — Devon County Council
Summary: We will not investigate Mrs X’s complaint about her child’s school, the contents of their Education, Health and Care Plan and the Council’s decision not to reassess their needs sooner. This is because it is reasonable to expect Mrs X to have used her right of appeal to a …
LGO (Local Government & …
Education
Sep 2024
24-018-393 — Derbyshire County Council
Summary: Mrs X complained the Council delayed in completing the review of her daughter’s Education, Health and Care plan. Because of this delay, she reported that her daughter stopped receiving some speech and language therapy provision and further provision through an occupational therapist. She also confirmed the Council failed to …
LGO (Local Government & …
Education
Upheld
Aug 2025
25-017-567 — Essex County Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Jan 2026
25-016-808 — Essex County Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Jan 2026
25-013-074 — Bury Metropolitan Borough Council
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Education
Jan 2026
25-012-427 — Lancashire County Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has offered an appropriate remedy for the injustice caused by the delay. An investigation by the Ombudsman would not lead to a different outcome.
LGO (Local Government & …
Education
Upheld
Jan 2026
25-012-309 — Nottinghamshire County Council
Summary: We will not investigate this complaint about the Council’s handling of an Education, Health and Care plan review. This is because the Complainant has appeal to the tribunal about the content of the plan and the law prevents us from also considering this issue. The Council has apologised for …
LGO (Local Government & …
Education
Jan 2026
25-002-009 — Manchester City Council
Summary: Ms X complained the Council failed to provide Z with a suitable education when he was unable to attend school. We have found the Council acted with fault for failing to maintain oversight of Z’s case and failing to ensure a timely referral to its decision panel. We also …
LGO (Local Government & …
Education
Upheld
Jan 2026
25-001-312 — Knowsley Metropolitan Borough Council
Summary: Mrs X complained the Council failed to provide the special educational provision detailed in her child, Y’s, Education, Health and Care Plan. We find the Council at fault for a delay in providing educational provision when it was aware the named setting was unable to meet Y’s needs. This …
LGO (Local Government & …
Education
Upheld
Jan 2026
25-001-244 — Devon County Council
Summary: There was no fault in how the Council considered and put in place alternative provision for Mr X’s child, Y between February 2024 and March 2025. The Council provided tuition for Y and then provided a place at its alternative provision placement in January 2025 without fault.
LGO (Local Government & …
Education
Not Upheld
Jan 2026
25-000-981 — Knowsley Metropolitan Borough Council
Summary: The Council was at fault in failing to provide Mrs X’s child, Y, with alternative education provision during the 2024/25 school year. As a result, Y missed out on education for a full academic year. The Council was also at fault in its handling of Mrs X’s complaint, which …
LGO (Local Government & …
Education
Upheld
Jan 2026
25-000-073 — Hertfordshire County Council
Summary: Mr X complained about the Council’s failure to provide his daughter, Y, with suitable education and support for her special educational needs and related matters. We found the Council to be at fault. It failed to ensure Y had access to appropriate support when she was unable to attend …
LGO (Local Government & …
Education
Upheld
Jan 2026
24-000-456 — South Gloucestershire Council
Summary: Mrs E and Mr E complained that the Council failed, over several years, to provide Mr E with suitable education, based on the contents of his Education, Health and Care Plan. We uphold the complaint because of delay in reviewing Mr E’s Plan, a delayed complaint response and incorrect …
LGO (Local Government & …
Education
Upheld
Jan 2026
25-012-635 — West Northamptonshire Council
Summary: We cannot investigate this complaint that the Council was at fault in the process of assessing the complainant’s child’s education, health and care needs and has issued a flawed Education Health and Care (EHC) plan. The complainant has used her right to appeal to the First-tier Tribunal (Special Educational …
LGO (Local Government & …
Education
Jan 2026
25-011-682 — North Yorkshire Council
Summary: We cannot investigate Mrs X’s complaint about the consultation process the Council followed when it named a placement in Miss Y’s Education, Health and Care Plan, or Mrs X’s view the Council failed to secure the content of Miss Y’s EHC Plan during a tribunal process. This is because …
LGO (Local Government & …
Education
Jan 2026
25-011-132 — Bury Metropolitan Borough Council
Summary: We cannot investigate part of Miss X’s complaint about how the Council consulted schools or the decision to name a specific school in her child’s Education, Health and Care (EHC) Plan because Miss X appealed to a tribunal and the law says we cannot investigate. We will not investigate …
LGO (Local Government & …
Education
Jan 2026
PSOW-202308836 — Betsi Cadwaladr University Health Board
Mrs A had complained to the Health Board about the care provided to her young child by the Neurodevelopment Team at Wrexham Maelor Hospital. She had also raised concerns with the Health Board via her local MS. The Health Board treated Mrs A’s concerns as an enquiry and responded to …
PSOW (Public Services Om…
Health
May 2024
PSOW-202503804 — Aneurin Bevan University Health Board
Ms A complained about the care and treatment afforded to her child, B, by Aneurin Bevan University Health Board (“the Health Board”). When the Ombudsman looked at the complaint, she was concerned that Ms A said she had not received a report which the Health Board had undertaken to send …
PSOW (Public Services Om…
Health
Nov 2025
24-000-038 — Stoke-on-Trent City Council
Summary: We will not investigate Miss B’s complaint about the contents of a court report and a social worker failing to attend a court hearing without notice. This is because the complaint concerns matters which have been considered in court or are closely related to those matters.
LGO (Local Government & …
Children S Care Services
May 2024
24-006-837 — Essex County Council
Summary: We will not investigate this complaint about the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Sep 2024
24-006-649 — Suffolk County Council
Summary: We will not investigate Mr X complaint about delay in issuing an Education Health and Care Plan. We are unlikely to achieve a significantly different remedy than already offered. We cannot investigate the content of the EHC Plan. And it is unlikely we would find fault in the Council’s …
LGO (Local Government & …
Education
Upheld
Sep 2024
24-006-257 — London Borough of Richmond upon Thames
Summary: We will not investigate Ms X’s complaint about the Council’s delay in issuing her daughter’s final Education Health and Care Plan and its failure to put in place sufficient speech and language therapy to meet her needs. This is because the injustice Ms X claims is not significant enough …
LGO (Local Government & …
Education
Oct 2024
23-019-454 — West Sussex County Council
Summary: Miss F complained the Council delayed issuing an Education, Health and Care Plan for her daughter and failed to provide her with a suitable full-time education when she was unable to attend school due to ill health. There was delay in issuing the plan. The Council should make a …
LGO (Local Government & …
Education
Upheld
Oct 2024
23-014-461 — Oxfordshire County Council
Mr X complained the Council failed to secure suitable education provision for J, or discharge its statutory education responsibilities, when J stopped attending school. Mr X said this led to J losing education provision, affecting J’s educational attainment and wellbeing. We have found the Council at fault for failing to …
LGO (Local Government & …
Education
Upheld
Oct 2024
24-017-714 — Wokingham Borough Council
Summary: We cannot investigate some of Miss X’s complaint about the content of her child, Y’s, Education, Health and Care Plan because she appealed to a Tribunal. We will not investigate the remaining matters regarding delay and poor communication because the Council apologised, and the remaining injustice is not significant …
LGO (Local Government & …
Education
Apr 2025
24-021-450 — Essex County Council
Summary: We will not investigate Mrs X’s complaint about delays in the Education Health and Care Plan process. This is because the Council has agreed to apologise to Mrs X and pay her £100 per month for the delay. We consider this an appropriate remedy and further investigation is therefore …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-009-698 — East Sussex County Council
Summary: Mrs Y complains the alternative provision offered by the Council was not suitable for her son, D, after he was permanently excluded from primary school. She also complains about delays in reviewing D’s Education Health and Care Plan. We find no fault in the alternative provision initially offered by …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-007-013 — Devon County Council
Summary: Miss X complained about delays in her son, Y’s, Education, Health and Care needs assessment. She said Y has been out of school since February 2023 and she incurred significant costs securing educational provision for him. Miss X said this frustrated and distressed her and Y. There was fault …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-010-382 — Kent County Council
Summary: Mr X complained about how the Council supported his child, Y’s, special educational needs. There was fault in how the Council failed to act when it became aware some of Y’s support was not being provided and in significant delays responding to Mr X’s complaint. The Council agreed to …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-005-411 — Hampshire County Council
Summary: Miss X complained the Council delayed issuing an education, health and care plan for her child, failed to provide sufficient alternative education, gave her misinformation about a placement, and communicated poorly with her. Miss X said this caused distress, meant she had to leave her job, and her child …
LGO (Local Government & …
Education
Upheld
May 2025
24-014-709 — City of Bradford Metropolitan District Council
Summary: Mr F complained the Council refused to provide home to school transport for his son (J) who has special educational needs. As a result, he has had to transport J causing a strain on his finances. Mr F also complained the Council failed to follow its appeals process and …
LGO (Local Government & …
Education
Upheld
Aug 2025
25-012-294 — Nottinghamshire County Council
Summary: We cannot investigate Mr X’s complaint about the Council’s conduct during court proceedings because the law says we cannot investigate what happened in court.
LGO (Local Government & …
Children S Care Services
Oct 2025
25-011-421 — Tameside Metropolitan Borough Council
Summary: We have upheld this complaint about delay in the children’s statutory complaints procedure. This is because the Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused.
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2025
Domestic Homicide Reviews(3)
Cardiff — recommendation 4
Child and Adolescence Mental Health Services examine its working practices and resilience to ensure that children receive appropriate support and care even in the event of sickness of senior member’s staff.
Child and Adolescence Mental Health Services
Oxford — recommendation 3
There needs to be further clarity about the service provision for young people who are excluded or not attending school, to ensure the school nursing service has the capacity to outreach to these vulnerable young people in partnership with other services.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Dudley — recommendation BCHC_1
Assurance required within the health visiting service that process is applied when there are workforce absences.
Birmingham Community Healthcare NHS Trust
Birmingham Community Healthcare NHS …
CQC enforcement actions(3)
Warning Notice: Cambridgeshire Community Services NHS Trust
CQC told Cambridgeshire Community Services NHS Trust it must make urgent improvements to comply with two national standards of quality and safety at its children’s inpatient services based at Hinchingbrooke Hospital. This followed an unannounced inspection on 3 September 2013, …
Holly Ward at Hinchingbrooke Hospital, Hinchingbr…
Oct 2013
Warning Notice: Basildon and Thurrock University Hospitals NHS Foundation Trust
The Care Quality Commission raised serious concerns regarding the quality of services at Basildon and Thurrock University Hospitals NHS Foundation Trust. These concerns included a poor care environment in A&E, inadequate arrangements for treating children, and breaches of infection control …
Nov 2009
Conditions Imposed: Tavistock and Portman NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions on the registration of Tavistock and Portman NHS Foundation Trust following an announced, focused inspection in October and November. Inspectors found significant concerns within the Gender Identity Development Services (GIDS), including over 4,600 …
Jan 2021