Chronic healthcare staff shortages
Persistent and unaddressed staff shortages in hospitals and care settings, leading to compromised patient care and burnout.
Source spread
Where this theme appears
This theme appears across 22 independent accountability sources, so the source mix matters as much as the headline total.
24 inquiry recs
280 PFD reports
320 committee recs
45 HSSIB recs
397 CQC actions
1 HMICFRS rec
9 PPO recs
6 NAO recs
1 PHSO rec
61 IMB recs
99 IMB reports
2 Scottish FAIs
1 detention investigation rec
16 DHR recs
3 PHSO decisions
39 LGO/SPSO decisions
24 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(24)
10 — At least four new consultant psychiatrists
Recommendation: At least four new consultant psychiatrists should be appointed to Whittingham Hospital, with appropriate junior staff, and in making appointments the special needs of long-stay psychiatric and geriatric patients should be borne in mind. There will need to be an …
Unknown
8 — Board review of staffing monitoring
Recommendation: The Board should review its monitoring of staffing levels in psychiatric hospitals.
Unknown
5 — Re-examine staffing monitoring arrangements
Recommendation: Deficiencies in staffing at Whittingham Hospital shown in annual returns to the Department and to the Board have not resulted in action to remedy them and we consider that monitoring arrangements need re-examination.
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
R98 — AHP and social care workforce recruitment
Recommendation: The DoH must devise ways to recruit and retain more allied health professionals and social care staff in the community for autistic people and people with learning disabilities.
No response yet
R9 — Integrated workforce plans
Recommendation: Each facility or service should have an integrated workforce plan that includes all allied health professionals (AHPs) and all staff involved in patient care. This should be based upon the assessed needs of the service user and must include protected …
No response yet
R36 — Medical staffing levels
Recommendation: Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high quality care.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
MAI-156 — Ambulance Liaison Officer resourcing
Recommendation: The Home Office, the Department of Health and Social Care and the National Ambulance Resilience Unit should consider how to ensure that the role of an Ambulance Liaison Officer is properly resourced and also whether venue operators should fund the …
Gov response: Accepted in full
Accepted
MAI-148 — LRF staffing and resources
Recommendation: The Home Office should consider, together with local resilience forums, how they are to have sufficient staff and resources to enable them to function effectively.
Gov response: Accepted in full
Accepted
MAI-86 — Arena healthcare provider staffing requirements
Recommendation: SMG should ensure that the healthcare service provider at the Arena has adequate staffing and skill levels for every event at that location.
Gov response: Accepted in full
Accepted
MAI-78 — Review NWAS Tactical Advisor numbers
Recommendation: North West Ambulance Service should review the number of Tactical Advisors and National Interagency Liaison Officers it has, and whether the number of such specialists, both generally and on call, should be increased.
Gov response: Accepted in full
Accepted
MAI-47 — Sufficient resources for operational planning
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should work together to put in place robust systems, policies and guidance to ensure that all police services have sufficient resources dedicated …
Gov response: Accepted in full
Accepted
MAI-44 — Ambulance trusts submit resource recommendations
Recommendation: Having carried out that review, the trusts should make recommendations to their NHS commissioners about the additional and/or different resources they require in order to ensure that they are able to respond effectively to a mass casualty incident in the …
Gov response: Accepted in full
Accepted
MAI-25 — Review embedding doctors with firearms teams
Recommendation: Counter Terrorism Policing Headquarters should review the evidence heard during the Inquiry, including that heard in restricted sessions, to consider the advantages and disadvantages of embedding doctors with some police firearms teams, and how, if that is advantageous, it could …
Gov response: Accepted in full
Accepted
MAI-10 — Resolve paramedic-driver shortage in mass casualties
Recommendation: A significant issue in a mass casualty situation is that all of those paramedics who have arrived in ambulances may be required for the treatment of casualties, so that no paramedic is available to drive patients to hospital. The Department …
Gov response: Accepted in full
Accepted
MAI-8 — Review mass casualty response capacity
Recommendation: Ambulance service trusts should review their capacity to respond to a mass casualty incident. That should include an assessment of whether they have an adequate number of trained specialist personnel to respond effectively to a mass casualty incident.
Gov response: Accepted in full
Accepted
26 — Recruit social workers with local authorities
Recommendation: A strong group of social workers should be recruited in association with the Local Authority Social Service Departments of Preston County Borough and Lancashire County and services built up along the lines set out in Chapter 7.
Unknown
R102 — Centralised workforce intelligence function
Recommendation: DoH should establish a comprehensive, centralised workforce intelligence function, similar to those in the rest of the UK, within 12 months of the publication of this report. The learning disability service model must include a fully funded, comprehensive workforce model, …
No response yet
IBI-7c — Transfusion Laboratory Staffing
Recommendation: Transfusion laboratories: Transfusion laboratories should be staffed (and resourced) adequately to meet the requirements of their functions.
Gov response: Work is ongoing to determine the current status of transfusion staffing, reviewing best practice from other areas including nursing, and developing an evidence base to inform minimum staffing level standards. The data for staffing is …
Accepted in part
SHI-8 — IPC role specifications and staffing levels
Recommendation: I accordingly recommend that priority be given to protecting scarce IPC resources. With that objective in view, what is expected of consideration and advice from individual disciplines at various stages of a project should be made clear. Job and role …
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
8 — Develop recruitment and retention strategy
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. This should include, but not be limited to, seeking links …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
IBI-7d — Training in Transfusion Medicine
Recommendation: Training in Transfusion Medicine: That those bodies concerned with undergraduate and postgraduate training across the UK of those people who are, or intend to be, working in the NHS ensure that they are adequately trained in transfusion, that the standards …
Gov response: The stakeholder group, including a range of professional and statutory bodies, have been working together to review and propose educational and training requirements. The group is currently collating patient safety e-learning material to provide a …
Accepted in part
20 — National review of maternity care in challenging circumstances
Recommendation: There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should identify the requirements to sustain safe services under these conditions. …
Gov response: 7. We accept this recommendation. A review of maternity care, which will also consider neonatal care and paediatrics in the context of maternity care, is underway. 8. In its report to Cumbria Clinical Commissioning Group, …
Accepted
21 — Consider extending review to other rural services
Recommendation: The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider the wisdom of extending the review of requirements to sustain …
Gov response: 11. We accept this recommendation in principle. NHS England are establishing Vanguard sites to explore how new models of care can address the challenges faced by services that are rural, geographically isolated or difficult to …
Accepted in part
Prevention of Future Deaths reports(280)— showing 50 strongest matches
Jordan Buckton
Concerns: Concerns were raised regarding inadequate information sharing within the prison about a person's history of self-harm and the lack of follow-up care, including a PHQ9 assessment, after antidepressant medication was prescribed.
Overdue
Luna Lesko
Concerns: The coroner noted delays in securing foetal monitoring and in performing a Category 2 C-section delivery, which exceeded Trust guidelines due to busy theatres. Expert evidence identified a real risk of preventable death due to insufficient out-of-hours theatre capacity.
Response (Lewisham Greenwich NHS Trust): • The Trust confirmed the introduction of middle grade obstetricians and anaesthetists from 2012 to ensure adequate cover for multiple emergency caesarean sections. • The Trust proposed to implement a … (AI summary)
Overdue
Jack William Payton
Concerns: The coroner observed that the workload and working hours of two control room staff appeared to detrimentally affect their judgement and subsequent handling of the incident.
Response (Avon and Somerset Police): • Avon and Somerset Police stated it would commission an independent assessment of current shift patterns and their effects on staff. • The findings of this assessment would be reviewed … (AI summary)
Responded
William Joseph Wilkinson
Concerns: Required one-to-one nursing was not consistently available, and a lack of direct orthopaedic input in the Emergency Department led to unnecessary admission. Also noted were incomplete fluid balance charts and staff difficulties with the computer system.
Overdue
Grace Mary Bates
Concerns: The coroner identified the lack of availability of a specialist diabetic nurse at the hospital over the weekend.
Response: • A business case for the appointment of a minimum of one specialist diabetic nurse was submitted and approved. • The appointment of a specialist diabetic nurse is awaited. (AI summary)
Response: • The NHS Services Seven Days a Week Forum developed ten clinical standards for urgent and emergency care, intended to reduce risks from weekend admissions, including for diabetes. • NHS … (AI summary)
Responded
Barry James Lewis
Concerns: The adequacy and availability of emergency surgical equipment in the ER, including appropriate sizes and out-of-hours theatre access, raised concerns. Also noted were night staffing levels for ODTs and ENT medical cover.
Response (The Pennine Acute Hospitals NHS Trust): • Emergency airway packs in all A&E departments were updated to include large instruments. • Equipment was unified across the trust, with input from ENT clinicians. • The role of … (AI summary)
Responded
Edna Elsie Mary Eden
Concerns: The coroner identified delays in a patient receiving prescribed antibiotics and doctor review, alongside infrequent nursing observations and an incorrect EDOD score that prevented escalation. Communication gaps meant nurses struggled to contact doctors, and junior staff did not escalate significant backlogs or concerns.
Response (Heatherwood Wexham Park Hospital NHS Trust): • The Trust introduced Policy TPP 231 in August 2013, which includes requirements for verifying EDOD score calculations and strengthens the use of the SBAR communication tool. • A new … (AI summary)
Responded
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends pose an increased risk of post-operative complications for vulnerable patients.
Overdue
Barry Dillion
Concerns: Insufficient resources for the Speech and Language Therapy service at Royal Blackburn Hospital lead to delays in swallow assessments, increasing the risk of aspiration pneumonia for patients.
Overdue
Neil Carter
Concerns: The coroner noted repeated failures to perform basic nursing observations, inadequate staffing levels and skill mix on the ward, and a lack of staff discipline. There was also a deliberate falsification of nursing records.
Response (CQC): • The CQC conducted multiple inspections of The Priory Hospital Roehampton, identifying non-compliance in areas such as staffing and observation training, and requiring the provider to take action. • Subsequent … (AI summary)
Response (Priory Group): • The individual responsible for record falsification and missing observations was dismissed and referred to the Nursing and Midwifery Council. • The hospital implemented changes to staff induction, reviewed its … (AI summary)
Responded
Lorna Cullen
Concerns: The coroner noted concerns regarding long waiting times for mental health assessments in hospital emergency departments, attributed to insufficient liaison psychiatry nurse staffing levels. The key issue identified was the long-term sustainability of adequate staffing after temporary funding for increased resources was set to expire.
Overdue
Christopher Williams
Concerns: The defibrillator machine was inoperable and had not been checked daily as required. There was no cross-check system or policy for the management of sudden unexpected deaths in place at the hospital.
Overdue
Robert Jones
Concerns: The coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Response: • The Health Board stated it would ensure CT scan results are made available promptly and routinely monitored. • The Radiology department will undertake sampling of scan-to-report times for emergency … (AI summary)
Responded
Phyllis Barnes
Concerns: The coroner noted a visiting GP did not fully appreciate the patient's serious post-operative condition, and a nurse-led telephone consultation appeared superficial. Additionally, there was no formal opportunity for the patient's daughter to relay her mother's condition to healthcare providers.
Overdue
William Winter
Concerns: Nursing staff on the Clinical Decisions Unit did not perform a second set of observations or escalate the need for a surgical review, partly due to high patient workload and unfamiliarity with escalation procedures.
Overdue
Frederick Hall
Concerns: The coroner noted a lack of skill and knowledge among staff regarding NG tube insertion and storage, alongside delayed responses to consultant instructions and patient deterioration. Deficiencies in communication between staff, poor record-keeping standards, and a need for more nursing/medical staff were also identified.
Overdue
Sari Keen
Concerns: Insufficient staffing levels led to staff feeling overwhelmed and unable to escalate care. Many staff were also unaware that an un-recordable blood pressure is a medical emergency requiring immediate resuscitation, suggesting a need to review crash team protocols.
Response (Luton Dunstable University Hospital): • The Trust confirmed processes are in place for adequate medical staffing and reinforced the importance of early escalation among staff. • A revised observation and escalation process is being … (AI summary)
Responded
Jennifer Morrison
Concerns: Missing hospital documentation, including patient observations, was noted to jeopardise post-death investigations. Concerns were also raised about delays in transfer to a High Dependency Unit and in treatment due to bed and staffing shortages after the holiday period.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): • The Trust confirmed it had a Health Records Management Policy, conducted regular audits, and was implementing an electronic patient record system from November 2014. • The Trust stated it … (AI summary)
Responded
Dayani Chauhan-Ahmed
Concerns: The coroner noted ineffective communication regarding the length of the second stage of labour to senior staff due to an unmonitored whiteboard system. There was also uncertainty among midwifery and medical staff concerning the updated escalation policy and adherence to its time limits.
Response (University Hospital of Leicester NHS Trust): • The Trust committed to reviewing and strengthening guidelines for the management of the second stage of labour, including guidance on using the emergency buzzer and ensuring sight of CTG … (AI summary)
Responded
Henry Marsh
Concerns: The Home Treatment Team had an excessive number of patients, which created difficulties in holding effective multi-disciplinary meetings due to the large caseloads.
Response (Department of Health): • NHS England intends to map best practice guidance on Crisis Home Treatment Teams onto the mental health intelligence network. (AI summary)
Responded
Christopher Royal
Concerns: The report describes unreliable and inaccurate patient observations, insufficient staff first aid training and response to a medical emergency, and questions the impact of 13.5-hour shifts on care quality.
Response (Royal 2014 0354): • The observation policy was reviewed, new record sheets were created, and monitoring of their completion was implemented. • The training system was reviewed, a skills matrix developed, and a … (AI summary)
Responded
Iris Grimwood
Concerns: The coroner identified difficulties in providing adequate nursing care, including errors in temperature measurement and incorrect medication application. These issues were attributed to insufficient nursing staff levels, recruitment challenges, and training funding problems.
Overdue
Thomas Taylor
Concerns: The coroner identified a lack of clear leadership and sufficient staffing on the ward. Additionally, there were no clear protocols for handling lost patient notes or for managing blood sugar monitoring, insulin administration, and escalation of care for hyperglycaemic patients.
Overdue
Yohannes Kidane
Concerns: Concerns were noted regarding inadequate night staffing on healthcare wards, which compromises the ability to conduct effective ACCT observations and affects staff welfare due to staff not taking breaks.
Response (HM Prison and Probation Service): • HM Prison and Probation Service reviewed night staffing levels at HMP Birmingham and concluded they were acceptable. • A Prison Custody Officer is deployed to patrol the healthcare centre … (AI summary)
Response (Birmingham Solihull NHS): • Birmingham Community Healthcare Trust reviewed its skill mix for Ward 1, which will result in the conversion of funding for unqualified staff into qualified nurses, with recruitment for an … (AI summary)
Responded
Anne Sandever
Concerns: The coroner noted a lack of nursing care, poor communication regarding Mrs. Sandever's diabetes, and that she was left without intravenous fluids despite renal failure. Additionally, the hospital's investigation into these issues was deemed insufficient.
Response: • The Trust introduced spot checks on wards and commenced a training programme for staff on recognising deteriorating patients and monitoring vital signs. • The Trust reviewed and updated its … (AI summary)
Responded
Joyce Nelson
Concerns: The coroner identified significant delays in doctor assessment and documentation of X-ray results in the Emergency Department due to staff busyness. There were also considerable delays in imaging result reporting, which nearly led to the discharge of a patient with a multi-fractured pelvis.
Overdue
Timothy Cowen
Concerns: Concerns were raised that new procedures and protocols training is not mandatory for all relevant staff. Additionally, there are insufficient Acute Liaison Nurses, and no cover is in place for their absences.
Overdue
Mary Fenton
Concerns: The coroner identified a lack of out-of-hours cardiology consultant cover, echocardiogram facilities, and qualified staff for pacing wire procedures at Tameside Hospital. Further concerns included patient capacity and consent issues, critical drug shortages, and communication failures.
Response (Department of Health): • The Department of Health confirmed Isoprenaline injection is an unlicensed 'special' product in the UK. • The Department of Health was aware of problems with Isoprenaline availability and issues … (AI summary)
Response (Tameside Hospital): • The Trust implemented a 24/7 on-call rota for Consultant Cardiologists for emergency temporary pacing, which became operational on 10 November 2014. • A specialist nurse in safeguarding adults, MCA, … (AI summary)
Responded
Betty Smith
Concerns: The coroner identified insufficient ITU bed capacity due to nursing shortages, inadequate anaesthetic pre-assessment for high-risk patients relying solely on medical records, and the failure to secure a High Dependency Unit bed post-operatively for such a patient.
Overdue
Thomas Jenkins
Concerns: The coroner noted slow response times for Tissue Viability Nurse input and inadequate wound care, attributed to specialist nurses not being hospital-based and an insufficient number of TVNs in the region.
Overdue
Elizabeth Leah
Concerns: The coroner raised concerns about an elderly patient with a broken leg being advised to take a taxi to hospital due to ambulance resource shortages. Insufficient ambulances and staff, exacerbated by A&E delays and bed blocking, were noted as issues requiring central government action.
Response (Department of Health): • NWAS increased staffing levels in control rooms and for road staff. • NWAS introduced Advanced Community Paramedics and expanded the use of volunteer services and Community First Responders. • … (AI summary)
Responded
Laura Hill
Concerns: The coroner identified gaps in information transfer between child and adult mental health teams and insufficient ward staffing. Concerns included the ward's door policy and staff training on absconding, Section 136 procedures, and powers of detention.
Response: • The Health Board provided and circulated transition guidelines for Specialist Child and Adolescent Mental Health Services to Adult Mental Health and Learning Disability Services. • The ward reviewed its … (AI summary)
Responded
Peter Wright
Concerns: The coroner identified concerns regarding significant ward understaffing, which led to one nurse caring for 16 patients and performing a drug round alone. Additionally, the report noted a lack of out-of-hours doctor cover at St George's Hospital.
Response (South Staffordshire Shropshire Healthcare NHS Trust1): • The Trust made additional investments in nursing establishments on a number of wards following a review presented in December 2014. • Brocton Ward's staffing establishment for 2015/16 was set … (AI summary)
Responded
Elizabeth Cox
Concerns: Concerns were raised regarding the lack of a night-time equivalent of the Reducing Harm Team for additional staffing. The coroner is also concerned that a proposed reduction in night staff could compromise patient safety due to increased workloads.
Response (Sherwood Forest Hospital): • The Trust implemented a 'Reducing Harms Team' in June 2013 to provide enhanced care for vulnerable patients. • A new staffing model, which includes 3 Registered Nurses and 1 … (AI summary)
Responded
Elsie Hayward
Concerns: Medical staff were caring for significantly more patients than a safe ratio, leading to an overstretched team and deficiencies in care. Neuro observations were not performed according to guidance, and poor note-taking caused communication issues between nursing and medical teams.
Response (Cardiff Vale University Health Board): • The Clinical Director for Internal Medicine worked with junior doctors to agree a process for covering short-term staff absences. • The 'core-care plan' and 'real time documentation' have been … (AI summary)
Responded
Sabrina Stevenson
Concerns: The coroner noted worsening ambulance response times, a significant staffing shortfall, and a lack of clear plans to address these issues. Concerns also include gaps in training for pregnancy assessment and patient extraction, and the non-implementation of suggested system improvements.
Response (College of Paramedics): • The College of Paramedics established an expert paramedic group. • This group will contribute to guidance on paramedic clinical practice for the profession. (AI summary)
Response (London Ambulance Service): • London Ambulance Service (LAS) outlined plans for significant investment, recruitment of 850 staff, and updates to its operating plan to address response times and staffing. • LAS described updates … (AI summary)
Response (NHS England1): • NHS England, Brent CCG, and the NHS Trust Development Agency conducted weekly operational performance reviews and commissioned a diagnostic review of underperformance. • An external clinical review of the … (AI summary)
Responded
Olive Nugent
Concerns: The coroner noted that the prioritisation of falls activator device responses was subjective, leading to delays for individuals unable to respond verbally, and that staffing levels were insufficient to meet demand.
Overdue
Paul Murray
Concerns: The London Ambulance Service had insufficient resources available to meet demand on 7th February 2013.
Response (Department of Health): • The Department of Health stated it continues to work with partners to monitor and support ambulance service performance and confirmed it would provide an additional £8 billion to the … (AI summary)
Responded
Barbara Patterson
Concerns: The Pathways system fails to prompt CPR advice for agonal breathing, a known fault Pathways has not amended. There were also delays in ambulance dispatch and arrival, partly due to paramedic shortages and hospital handover delays.
Response (Department of Health): • The NHS Pathways system is subject to ongoing review and updates, with amendments made to supporting information on breathing assessment. • The North East Ambulance Service has reduced its … (AI summary)
Response (CQC): • The CQC was monitoring an action plan submitted by North East Ambulance Service (NEAS) following previous inspections in February 2014 where non-compliance was identified. • The CQC intends to … (AI summary)
Response (North East Ambulance Service NHS Trust): • The Trust had conducted an investigation into the issues raised. • The Trust had provided management evidence regarding the issues. (AI summary)
Responded
John Bartle
Concerns: The family perceived a lack of staff over a Bank Holiday weekend, leading to delayed interventions, poor nutritional support, and inadequate pain control. Concerns were also raised about poor communication from nursing staff.
Overdue
Stanley Oliver
Concerns: The coroner noted the absence of an out-of-hours on-call rota for GI Radiologists to perform urgent procedures like percutaneous cholecystostomy, identifying this as a national issue that poses a risk to patient management.
Response (S Oliver): • The Trust updated a Standard Operating Procedure to incorporate support from Central Manchester NHS Foundation Trust for weekend non-vascular intervention services. • The Trust committed to developing a non-vascular … (AI summary)
Response (Department of Health): • NHS England has been working with the British Society for Interventional Radiology to improve access to interventional radiology across England. • Clinical standards for seven-day services were developed, including … (AI summary)
Responded
Arthur Cook
Concerns: The coroner identified low staffing levels for Tissue Viability Nurses, inadequate pressure ulcer documentation and repositioning charts, and a lack of integrated skin care within and between health boards and primary healthcare services.
Overdue
James Adams
Concerns: Concerns were raised regarding the shortage of acute psychiatric beds in Cornwall and inadequate staffing at designated mental health places of safety. This leads to patients being inappropriately detained in police cells or transported out of county.
Response (James Adams): • The working relationship between Devon and Cornwall Police and local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up. • Kernow CCG has … (AI summary)
Responded
William Harnell
Concerns: The coroner noted national delays in X-ray reporting, attributing this to a shortage of qualified radiologists.
Response (Department of Health): • Health Education England (HEE) increased radiology training places, advertising 212 posts in 2015, including 16 new positions. • Radiologists were added to the Shortage Occupation List in April 2015 … (AI summary)
Response (Plymouth Hospital NHS Trust): • The Trust confirmed that Emergency Department and inpatient films from Sunday morning to Friday evening are reported within 24 hours through a revised system. • The Trust developed a … (AI summary)
Response (william harnell): • Staff in the dedicated Social Work Service at Derriford Hospital have been reminded of the requirements to seek timely placements. • The team will work with health colleagues to … (AI summary)
Responded
Leslie Murray
Concerns: Insufficient staff cover for 1:1 patient care on Holdsworth ward, and likely other wards, leads to preventable falls and care deficiencies that may contribute to death.
Overdue
Matthew Crowley
Concerns: The coroner identified delays in A&E assessment due to staffing and an inoperable protocol. Concerns also included on-call consultants lacking updated patient deterioration information, leading to delayed decisions and issues with transfer communication.
Overdue
Freda Weston
Concerns: Insufficient doctor and nurse staffing led to significant delays in antibiotic administration and patient review. The report also notes issues with adherence to escalation guidelines, clarity of pharmacy medication details, and immediate shredding of handover sheets.
Response (Weston): • The Trust stated it would not alter its current practice regarding Septrin usage or implement a period of observation after starting Septrin, citing clinical reasoning. • The Trust clarified … (AI summary)
Responded
Adam Rice
Concerns: The coroner noted that clinicians should inform police about self-discharged patients requiring further investigation, and raised issues regarding West Yorkshire Police custody staff's knowledge of relevant acts and codes, as well as staffing levels during high demand.
Response (Adam Rice): • West Yorkshire Police confirmed that all custody staff receive initial and annual refresher training on relevant legislation and professional practice. • West Yorkshire Police is recruiting additional Detention Officers … (AI summary)
Overdue
Mandeep Singh
Concerns: The coroner noted severe demand and staff shortages within the North East Ambulance Service division contributed to ambulance arrival delays, further impacted by road closures and diversions.
Response (North East Ambulance Service): • The Trust has implemented initiatives to manage demand, including public education campaigns and a trial scheme with Fire and Rescue Services for Emergency Medical Responders. • The Trust has … (AI summary)
Responded
Marina Fagan
Concerns: The coroner noted insufficient neurologists nationally, contributing to delays in specialist neurological input, including a lack of out-of-hours on-call neurologists at the admitting hospital and lengthy outpatient waiting times.
Response (Department of Health): • Health Education England (HEE) has consistently invested in commissioning neurology training places. • HEE intends to commission 219 neurology training places in 2016/17. (AI summary)
Responded
Select committee recommendations(320)— showing 50 strongest matches
#30 —
Recommendation: Public bodies are facing challenges recruiting and retaining ecological expertise. It is necessary to bring expertise into the system through recruitment or training current staff.
Response attribution not verified
#199 —
Recommendation: The Probation Service is understaffed. The National Audit Office told us that âin December 2022, 1,762 out of 6,158 Probation Officer roles were unfilled, a vacancy rate of 29%â. 373 Academics from Sheffield Hallam University confirmed that, as of March …
Response attribution not verified
#132 —
Recommendation: Besides caseloads, Justin Russell told us that the Youth Offending Services have âvery stable staff groups, very low vacancy ratesâ, and âstaff remaining in post for long periods of timeâ, including senior members of staff being in post since YOSs …
Response attribution not verified
#12 —
Recommendation: Many people on probation suffer from mental health issues and from addiction to alcohol or drugs, which fuels their offending behaviour. Few of them are referred to a Community Sentence Treatment Requirement (CSTR). And yet, referrals exceed the availability of …
Response attribution not verified
#38 —
Recommendation: We recommend that the Department for Culture, Media and Sport, and the Ministry of Housing, Communities and Local Government work together to develop targeted and sustained support to increase the 54 number of conservation officers and heritage specialists within local …
Response status not verified
#28 —
Recommendation: Workforce and skills shortages now pose one of the most serious risks to the long-term protection of the UK’s built heritage. An ageing workforce, limited training routes, insecure funding and declining local authority 52 expertise are combining to create a …
Response status not verified
#23 —
Recommendation: We heard of one element of an ICB that currently has 40 people in place but which will have one person discharging that responsibility from April 2026. We are not convinced that this reorganisation has been thought through properly and …
Response attribution not verified
#22 —
Recommendation: In March 2025, the government announced it would abolish NHS England and change the responsibilities of ICBs.43 In April 2025, NHSE announced that ICBs had to make 50% cost reductions.44 To achieve this, ICBs are planning large scale redundancies and …
Response attribution not verified
#16 —
Recommendation: NHSE was clear that the “ position we are in is not acceptable”.34 The Chief Medical Officer also explained that to understand GPs’ capacity, it is important to factor in geographic or demographic pressures. These could include rural or peripheral …
Response attribution not verified
#15 —
Recommendation: We were concerned that GPs might not be prioritising care for those with or at risk of frailty. NHSE acknowledged that GPs were not formally assessing enough of their patients for frailty.32 NHSE recognised that it had pushed GP practices …
Response attribution not verified
#14 —
Recommendation: NHSE also told us that it was about to write to ICBs, as part of the framework for neighbourhood health, with the key requirements that ICBs need to have in place next year around enabling better, more appropriate care for …
Response attribution not verified
#10 —
Recommendation: NHSE acknowledged the scale of variation and that tackling variation was one way it was trying to improve performance overall.20 NHSE told us that the reasons for variation will be different in different places. For example, some areas may have …
Response attribution not verified
#6 —
Recommendation: We remain deeply concerned that cuts to ICBs are insufficiently thought through and will undermine their ability and capacity to carry out their functions. It is unclear what oversight roles ICBs will retain under NHSE’s plans to make them into …
Response attribution not verified
#4 —
Recommendation: NHS England has overloaded GPs, who have limited capacity, with new and expanding priorities. NHSE has prioritised improving patients’ access and digital access to general practice. It recognises that pushing to improve one aspect of care inevitably causes consequences to …
Response attribution not verified
#11 —
Recommendation: In addition, we recommend that both the UK and Scottish Governments should consider increasing the number of ‘on the ground’ public health officials in key advisory roles to complement the expertise of academics.
Response attribution not verified
#23 —
Recommendation: We were concerned about the NHS needing to call on the same staff who have already worked exceptionally long hours during the first peak in order to deal with the backlogs of treatment, while also standing ready for a potential …
Response attribution not verified
#20 —
Recommendation: NHSE&I explained that the NHS was carrying 100,000 staff vacancies going into the pandemic.58 It said the workforce had been boosted by around 20,000 students; retired NHS staff; and a further 600,000 volunteers (working across a range of public services, …
Response attribution not verified
#28 —
Recommendation: NHSE&I acknowledged that COVID-19 has had a disproportionate impact on Black, Asian and minority ethnic (BAME) staff and admitted that there is variability in how well these staff have been supported during the pandemic. In response to our questions 64 …
Response attribution not verified
#27 —
Recommendation: NHSE&I noted that over 32,000 nurses stepped up to support the NHS during the COVID-19 outbreak, including former nurses and over 20,000 students. However, it acknowledged that there needs to be better local systems for retaining these returners, such as …
Response attribution not verified
#25 —
Recommendation: NHSE&I acknowledged that there are worrying signs of stress and burnout amongst NHS staff since the COVID-19 outbreak. It cited figures from a Nursing Times survey, 56 C&AG’s Report, para 2.6. Based on England-domiciled applicants, UK universities, and includes midwifery …
Response attribution not verified
#24 —
Recommendation: In December 2019, the government announced the introduction of a new maintenance grant for nursing students from September 2020, which consists of a non-repayable grant of £5,000 to £8,000 to help with living costs. Students will still pay their own …
Response attribution not verified
#23 —
Recommendation: Since 2017, the number of people accepted onto nursing and midwifery degree courses has increased from 22,045 in 2017 to 23,060 in 2019. This still means that, in 2019, only 430 (2%) more people accepted a place on a nursing …
Response attribution not verified
#22 —
Recommendation: The policy change impacted on some students and regions more than others. For example, from 2016 to 2018, there was a 10% increase in the number of students accepted onto nursing degree courses for children’s nursing and for applicants from …
Response attribution not verified
#21 —
Recommendation: From 2017, the Department changed the funding arrangements for nursing, midwifery and allied health professional students. Prior to 2017, HEE paid tuition fees to universities and NHS bursaries to students to cover their living costs. Instead, these students moved onto …
Response attribution not verified
#20 —
Recommendation: NHSE&I emphasised that retaining staff is a “valid and important” supply route, which represents the “best investment” for increasing numbers. It told us the main factors affecting retention include staff feeling stressed by the work, lack of flexibility and a …
Response attribution not verified
#9 —
Recommendation: The Department acknowledged that the demand for nurses and the extent of nurse shortages vary between specialisms and regions.14 For example, in the period July– September 2019, NHS trusts in England reported an overall nursing vacancy rate of 12%, but …
Response attribution not verified
#4 —
Recommendation: The nursing needs of social care remain an unaddressed afterthought for the Department of Health & Social Care. Vacancies for nurses in social care have increased from a rate of 4.1% in 2012–13 to 9.9% in 2018–19, while the number …
Response attribution not verified
#3 —
Recommendation: We are not convinced that the Department has plans for how the NHS will secure 50,000 more nurses by 2025. The Department plans to meet the 50,000 commitment by increasing the domestic supply of registered nurses, recruiting from overseas and …
Response attribution not verified
#32 —
Recommendation: We recommend again, that Health Education England publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years including an assessment of whether sufficient numbers are being trained. We further recommend that …
Response attribution not verified
#31 —
Recommendation: It is clear that workforce planning has been led by the funding envelope available to health and social care rather than by demand and the capacity required to service that demand. Furthermore, there is no accurate, public projection of what …
Response attribution not verified
#16 —
Recommendation: We repeat our recommendation that HEE must be required (whether in its own right or as part of NHS England) to publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years, …
Response attribution not verified
#21 —
Recommendation: Among comparable OECD countries the UK has relatively low numbers of hospital beds, nurses and doctors per 1,000 population and also carries out relatively low numbers of advanced diagnostic examinations.46 NHSE&I told us that it would take two to three …
Response attribution not verified
#10 —
Recommendation: Between 2010 and 2019 the NHS saw an average annual growth in emergency admissions of more than 3% and in urgent cancer referrals from GPs of more than 10%. Although there was relatively strong growth in the number of consultants …
Response attribution not verified
#3 —
Recommendation: The NHS will be less able to deal with backlogs if it does not address longstanding workforce issues and ensure the existing workforce, including in urgent and emergency care and general practice, is well supported. NHSE&I believes it will be …
Response attribution not verified
#21 —
Recommendation: As part of the long-term plan for the cancer workforce, the Government and NHS England should develop specific proposals for improving the retention of experienced cancer staff, including targeting burnout and improving the day-to-day working conditions of staff. (Paragraph 115) …
Response attribution not verified
#17 —
Recommendation: The Government and the NHS have recognised some of the issues with radiotherapy delivery in the NHS and have made welcome commitments to resolve these, such as investing in new radiotherapy machines and the proton beam centres in Manchester and …
Response attribution not verified
#17 —
Recommendation: The January 2019 NHS Long Term Plan originally committed to producing a workforce implementation plan by late 2019. In September 2020, the Department told us that it expected to publish the workforce plan following the December 2020 Spending Review.59 In …
Response attribution not verified
#16 —
Recommendation: We have been raising concerns about the lack of long-term planning for the NHS workforce since well before the COVID-19 pandemic52. We have noted that among comparable OECD countries the UK has relatively low numbers of nurses and doctors per …
Response attribution not verified
#3 —
Recommendation: The Department has started taking some action to address workforce challenges in social care, but vacancies have increased by 50% in the last year and the number of people working in social care fell in 2021/22 for the first time …
Response attribution not verified
#2 —
Recommendation: We remain very concerned about the critical shortages across the NHS workforce and the Department’s repeated delays in publishing a strategy to address them. Workforce shortages are widespread across the NHS, and particularly acute in some specialisms, for example midwifery. …
Response attribution not verified
#18 —
Recommendation: The Government need to publish an evidence-based plan, supported by up-to-date workforce modelling, setting out how it will increase the capacity and sustainability of all sectors of the specialist palliative and end of life care workforce, as part of the …
Response attribution not verified
#17 —
Recommendation: Current shortages in the specialist workforce are putting palliative care services in an unsustainable position which threatens their ability to deliver equitable and high-quality palliative and end of life care. Extensive consultant vacancies, impending retirements, limited training places and widespread …
Response attribution not verified
#27 — Government lacks a comprehensive long-term plan for the social care workforce
Recommendation: The Department informed us that the government has not set out an equivalent long-term plan for the social care workforce, because they are mainly private employees of independent companies.78 It told us, however, that there are steps it had been …
Response attribution not verified
#24 — NHS Long Term Workforce Plan addresses projected shortfall of up to 360,000 staff.
Recommendation: In the workforce plan, NHS England estimates that over a 15-year period, without action, there would be a shortfall of 260,000 to 360,000 staff by 2036–37. NHS England explained that, because it takes time to train people and that they …
Response attribution not verified
#18 — Adult social care workforce vacancies remain high and are worse in rural areas
Recommendation: We have repeatedly raised concerns about care workforce shortages. When we reported in 2018, vacancy rates for 2016–17 were 6.6%.38 The vacancy rate has increased since then and, as the NAO reported, in 2022–23 vacancies were 152,000, a rate of …
Response attribution not verified
#4 — Set out plan to lead sector in addressing chronic adult social care workforce challenges.
Recommendation: Notwithstanding its recent efforts to make adult social care a more attractive career, the Department has still not produced a convincing plan to address the chronic staff shortages in the long-term. Workforce vacancies in adult social remain worryingly high with …
Response attribution not verified
#41 — Women's health hub model shows promise but faces systemic challenges and risks unequal access.
Recommendation: The expansion of the women’s health hub model has the potential to be a positive step towards providing the joined-up care and commissioning needed to effectively support women experiencing reproductive health conditions. However, the women’s health hub model exists within …
Response attribution not verified
#15 — Complex patient needs, longer hospital stays, and staff sickness impede NHS productivity recovery.
Recommendation: We asked witnesses why NHS productivity continues to be lower than before the pandemic. NHSE told us the NHS currently has 19% more staff compared to before the pandemic but is only seeing 14% more patients. It named several factors …
Response attribution not verified
#11 — NHSE confident in future pandemic funding, but highlights workforce capacity as main concern.
Recommendation: Resilience to shocks is a key element of financial sustainability. We asked how well the NHS would cope financially in the event of another pandemic. NHSE expressed confidence that in the event of another pandemic government would provide any additional …
Response attribution not verified
#3 — Set out detailed plan for unprecedented NHS productivity gains, addressing staff retention.
Recommendation: NHSE displays a remarkable complacency about the realisation of future NHS productivity improvements, which, if achieved, would be unprecedented. According to official ONS measures, long-term productivity gains in the NHS averaged 0.6% a year over the period 1996–97 to 2018–19. …
Response attribution not verified
HSSIB safety recommendations(45)
Electronic patient record systems – electronic referrals for ongoing care
HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of advice and guidance processes, including as part of single point of access. This is in order to address the varying risks to patient safety created …
Safety Recommendation
Mental health: attempted suicide while under the care of community services
Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
Area of Improvement
Wrong patient details on blood sample
Trusts should be aware of the increased risk of WBIT incidents occurring where there may be staff shortages and staff fatigue.
Learning Prompt
The diagnosis of ectopic pregnancy
There is insufficient capacity to meet the demand for sonography if early pregnancy units are to deliver a seven-day-a-week service. It may be beneficial for NHS England/Improvement and Health Education England to carry out a workforce review to identify a …
Safety Observation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Work demands and capacity to respond Changes were identified in work processes, staffing levels and physical layout of the space in which staff were working, resulting from the pandemic. Membrane sweeps (a midwife or doctor uses a single finger to …
Learning Prompt
Recognition of the acutely ill infant
It may be beneficial if there is system-wide assessment of the capacity of the medical and non-medical workforce to support safe and sustainable staffing in emergency departments caring for children in England. The intention of the following safety observation is …
Safety Observation
Medicine omissions in learning disability secure units
It may be beneficial if organisations that use mental health nurses to cover shortages of registered learning disability nurses review their clinical model and conduct a training needs analysis. The aim of this would be to identify skills or training …
Safety Observation
Variations in the delivery of palliative care services to adults
Include palliative and end of life care in strategic workforce plans to ensure staffing of services is appropriately capable and can provide the capacity needed to meet demand.
Safety Action
Variations in the delivery of palliative care services to adults
HSIB recommends that NHS England commissions palliative and end of life care career pathways, ensuring that they include staff from the allied health professions, in order to build specialist workforce capacity.
Safety Recommendation
Mental health inpatient settings
HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes …
Safety Recommendation
Sepsis: a patient with diabetes and a foot infection
Out of hours expertise in diabetes and foot problems at Hospital A.
Area of Improvement
Inadvertent administration of an oral liquid into a vein
It is recommended that NHS Improvement undertake a formal evaluation of banding, time and resource given to the Medication Safety Officer role across England and publish its findings and mandate minimum resources and standards.
Safety Recommendation
Oxygen issues during the COVID-19 pandemic
It may be beneficial if national NHS recruitment and training programmes for engineering and estates professionals were developed to address existing challenges with the estates and facilities workforce.
Safety Observation
Medicine omissions in learning disability secure units
HSIB recommends that NHS England and NHS Improvement develops the ongoing work to improve the retention of learning disability nurses, in line with the intent of the All-England plan for learning disability nursing.
Safety Recommendation
The use of an appropriate flush fluid with arterial lines
It may be beneficial to recognise that workload and fatigue will influence the reliability of safety controls dependent on staff time and attention.
Safety Observation
12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence
Ambulance services and national organisations can improve patient safety by providing and supporting protected time and resources for paramedic training and continuous professional development, while understanding the potential impact on operational performance.
Safety Observation
The impact of staff fatigue on patient safety
Government and national organisations can improve patient safety by accounting for the impact of staff fatigue on patient safety when developing national priorities for NHS services.
Safety Observation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that The Shelford Group reviews and updates the Mental Health Optimal Staffing Tool on a regular basis following collection of recent data from mental health inpatient settings. This is to ensure the tool remains valid for potential changes …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to take rest breaks and reduce the risk of staff fatigue?
Learning Prompt
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
Area of Improvement
Lack of timely monitoring of patients with glaucoma
It is recommended that the Royal College of Ophthalmologists, working with relevant stakeholders, develop models and review workforce required for the optimal delivery of glaucoma care. The models should be tested and evaluated. It is recommended that the Royal College …
Safety Recommendation
The impact of staff fatigue on patient safety
Has your organisation considered the principles and activities described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation’s risk register identify fatigue risks?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation measure and monitor data relating to fatigue risks?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation consider how the design of work processes can help to reduce fatigue?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation have a person responsible for leading on fatigue risks?
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk when responding to patient safety events
Learning Prompt
The impact of staff fatigue on patient safety
Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Learning Prompt
The impact of staff fatigue on patient safety
Has your organisation considered the principles and activities described in the Chartered Institute of Ergonomics and Human Factors white paper ‘Fatigue risk management for health and social care’?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation’s risk register identify fatigue risks?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation measure and monitor data relating to fatigue risks?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation capture data on fatigue through existing reporting and learning mechanisms?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation consider how the design of work processes can help to reduce fatigue?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk from a systems perspective to account for both individual and organisation factors impacting on staff fatigue?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation offer training and support to staff on fatigue risks and how these can be managed?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation have a person responsible for leading on fatigue risks?
Safety Action
The impact of staff fatigue on patient safety
Does your organisation consider fatigue risk when responding to patient safety events
Safety Action
The impact of staff fatigue on patient safety
Does your organisation’s senior leadership understand fatigue risks and its link to patient safety?
Safety Action
The impact of staff fatigue on patient safety
Healthcare organisations and professional bodies can improve patient safety by including aspects of fatigue when conducting staff surveys in order to help build an understanding of the level of fatigue and any impact on staff performance and patient safety. This …
Safety Observation
The impact of staff fatigue on patient safety
Research funding and commissioning bodies can improve patient safety by prioritising future research to measure and assess the impact of staff fatigue on staff and patient safety. This should include patient experience and the health economics of staff fatigue due …
Safety Observation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
Those involved in the provision of undergraduate and pre-registration education (educational institutions and placement providers) and preceptorship/induction programmes can improve patient safety by collaboratively ensuring that staff entering mental health related professions are developing the required knowledge and skills, including …
Safety Observation
NCEPOD recommendations(10)
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
CQC inspection actions(397)— showing 50 strongest matches
Worthing Hospital
The trust must ensure there are enough nursing staff to keep patients safe.
Must Do
Worthing Hospital
The trust must ensure there are sufficient numbers of suitably qualified staff to keep patients safe.
Must Do
Worcestershire Royal Hospital
The trust should ensure enough provision of a critical care physiotherapists in line with national critical care standards.
Should Do
Worcestershire Royal Hospital
The trust should ensure there is enough provision of specialist critical care pharmacist in line with national critical care standards.
Should Do
William Harvey Hospital
The trust should ensure they have enough Allied Health Professionals available to provide care to patients on medical wards, including those in escalation areas where medically fit patients reside.
Should Do
West Suffolk Hospital
The service must ensure its staffing levels meet acuity levels within the service.
Must Do
Westmorland General Hospital
The service must ensure they deploy sufficient suitably competent and experienced staff and ensure all staff receive appropriate skills and drills training and professional development to enable them to maintain competency given the low numbers of deliveries.
Must Do
Westmorland General Hospital
The service must ensure that women presenting in labour have immediate access to suitable qualified and skilled midwifery staff.
Must Do
Westmorland General Hospital
The service must ensure there are sufficient maternity staff with the right qualifications, skills, training and experience to keep women safe from avoidable harm and to provide the right care and treatment.
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
Watford General Hospital
The trust must ensure that there are enough midwives to provide a safe service for women and does not limit their choice of the delivery environment.
Must Do
University Hospital of Hartlepool
The service must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people’s care and treatment needs.
Must Do
University Hospital Lewisham
The service should continue to address the vacancy rates in the service.
Should Do
The York Hospital
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must Do
The York Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
The York Hospital
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must Do
The York Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced midwives to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for …
Must Do
The Spalding GP Surgery
Continuetomonitorstaffinglevelsatthepracticesothatenoughsupportismadeavailabletoclinicalstafftomanage workloadsatthepractice.
Should Do
The Spalding GP Surgery
Continuetomonitorstaffinglevelsatthepracticesothatenoughsupportismadeavailabletoreceptionand administrativestafftomanageworkloadsatthepractice.
Should Do
The Princess Royal Hospital
The trust should ensure there is consistent leadership and staffing on the escalation wards.
Should Do
The Princess Royal Hospital
The trust should ensure nursing and healthcare assistant staffing levels are as planned.
Should Do
The Princess Alexandra Hospital
The trust should ensure their medical staffing meets the demand of patients overnight to avoid lengthy delays.
Should Do
The Ipswich Hospital
The service must ensure all steps are taken to appropriately manage and maintain safe staffing in the maternity unit.
Must Do
The County Hospital
The provider must ensure it has sufficient numbers of suitably qualified, competent, skilled and experienced staff who receive such appropriate training to carry out the duties they are employed to perform and ensure staff are trained to the right competency …
Must Do
St Richard's Hospital
The trust must ensure there are enough nursing staff to keep patients safe.
Must Do
Southport & Formby District General Hospital
The trust should continue to address the number of medical staffing vacancies across the medical care service.
Should Do
Southport & Formby District General Hospital
The trust should continue to act to address the high number of registered and unregistered nursing vacancies.
Should Do
Scarborough Hospital
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must Do
Scarborough Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
Scarborough Hospital
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must Do
Scarborough Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
Salford Royal Hospital
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Salford Royal Hospital
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Salford Royal Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Salford Royal Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Salford Royal Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Salford Royal Hospital
The trust must ensure that there are sufficient numbers of nursing and medical staff that can meet people's care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The service must ensure that they have enough medical or nursing staff to keep patients safe and that patients requiring one to one observations receive this level of care.
Must Do
Salford Royal Hospital
The service must ensure that there are sufficient numbers of both medical and nursing staff that can meet people's care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The trust must ensure that there are sufficient numbers and skill mix of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The service must ensure that there are sufficient numbers and skill mix of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The trust must ensure that services are always safely staffed by people with the necessary skills, knowledge and experience.
Must Do
Saint Mary's Hospital
The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)
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
Royal Victoria Infirmary
The service must ensure that there are sufficient numbers of competent, skilled, and experienced midwifery and medical staff to meet minimum staffing levels and meet the care and treatment needs of women, birthing people, and babies. This includes but is …
Must Do
Royal Victoria Infirmary
The service must ensure that there are sufficient numbers of suitably competent, skilled, medical staff to meet minimum staffing levels and meet the care and treatment needs of service users.
Must Do
Royal Shrewsbury Hospital
The trust should ensure there is consistent leadership and staffing on the escalation wards.
Should Do
Royal Shrewsbury Hospital
The trust should ensure nursing and healthcare assistant staffing levels are as planned.
Should Do
Royal Preston Hospital
The service should ensure the maternity assessment service has the right number of qualified staff and the triage telephone line is answered and monitored by a trained midwife.
Should Do
HMICFRS recommendations(1)
PPO death in custody recommendations(9)
The Head of Healthcare and Greater Manchester Mental Health Services
The Head of Healthcare and Greater Manchester Mental Health Services should consider what additional support can be put in place to address staffing shortages at Garth and consider how they can reasonably deliver a meaningful healthcare resource.
The Head of Healthcare (HMP Nottingham)
The Head of Healthcare should ensure there is adequate staffing within the mental health team to allow the team to provide the service for which it is commissioned.
The Director General of Prisons and MoJ People Group
The Director General of Prisons and MoJ People Group should consider what additional support can be put in place to address staffing shortages at Humber and consider how it can reasonably deliver a meaningful regime and deliver key work in …
The Head of Healthcare
The Head of Healthcare should develop a workforce strategy to address chronic understaffing as a matter of urgency.
The Director General of Prisons
The Director General of Prisons should urgently consider what additional support can be put in place to address staffing shortages at The Mount and how the prison can reasonably be expected to deliver an effective drug strategy and regime.
Manx Care
Manx Care should ensure there is a dedicated lead pharmacy provision at Isle of Man Prison and there is a prescriber available every day, even if that is for remote prescribing.
The Department of Health and Social Care and Manx Care
The Department of Health and Social Care and Manx Care should review the current provision of mental health services at Isle of Man Prison and provide a dedicated mental health service, which is sufficiently resourced to meet the needs of …
The Director General of Prisons
The Director General of Prisons should urgently consider what additional support can be put in place to address staffing shortages at The Mount and consider, as a matter of urgency, how it can reasonably be expected to deliver an effective …
The healthcare provider
The healthcare provider should ensure there is a GP onsite in line with the primary care service specification for prisons in England.
NAO audit recommendations(6)
The adult social care market in England
b) develop a workforce strategy, in line with its previous commitments, to recruit, retain and develop staff, aligned with the NHS People plan where appropriate;
Accepted
Progress in improving mental health services in England
b) Either separately or as a distinct part of the overall NHS workforce plan due in 2023, DHSC and NHSE should publish a longer-term mental health workforce recruitment and retention strategy and a costed plan, that reflects the volume and …
Accepted
The rollout of the COVID-19 vaccination programme in England
In the light of the expanded and accelerated booster programme, NHSE&I should take additional steps to manage the vaccine workforce and its welfare sustainably, and to examine how the programme can minimise its potential adverse impact on other health and …
Accepted
Resilience to animal disease
e work with stakeholders in the veterinary sector to develop a workforce strategy that addresses the challenges currently facing the veterinary workforce, particularly in government but also considering the private sector;
Accepted
Child Maintenance Client Funds Accounts 2020-21: 1993 and 2003 Schemes Account
• allocates sufficient resource to provide appropriate customer service and timely responses to queries and complaints on cases; and
Partially accepted
Child Maintenance Client Funds Account 2019-20
• allocates sufficient resource to provide appropriate customer service and timely responses to queries and complaints.
Partially accepted
IMB annual reports(99)— showing 50 strongest matches
Eastwood Park (2022)
HMP/YOI Eastwood Park faced a challenging reporting year (Nov 2021 – Oct 2022), marked by critical staffing shortages (17.5% below target), two deaths in custody, and exceptionally high self-harm levels, leading the IMB to no longer consider it safe for all women. The prison struggled with an increasing number of women with complex mental health needs, exacerbated by inadequate facilities and a lack of external secure placements, resulting in extended periods of segregation for some. Despite these issues, the Board commended staff professionalism, welcomed the new ONE women’s centre, and noted the prison’s high functional skills achievements.
PRISON
Key concerns
Foston Hall (2022)
HMP/YOI Foston Hall faced significant challenges in the reporting year, primarily due to acute staff shortages which severely impacted the regime, leading to frequent curtailments and long periods of cell confinement. Key concerns included high levels of self-harm and violence, inadequate accommodation, and slow progress in healthcare provision and resettlement outcomes. Despite these difficulties, the Board commended staff dedication and noted some improvements, such as the opening of better quality accommodation and enhanced chaplaincy services.
PRISON
Key concerns
Norwich (2023)
The IMB report for HMP/YOI Norwich highlights persistent staff shortages as the overarching issue, leading to a restricted regime with prisoners locked up for extended periods daily. Key concerns include high levels of self-harm and violence, an overstretched mental health team, and a lack of purposeful activity and rehabilitation programs for long-term and IPP prisoners. The Board also notes the inhumane detention of foreign national prisoners beyond their sentences and prisoners with severe mental health issues in unsuitable facilities.
PRISON
Key concerns
Low Newton (2023)
HMP/YOI Low Newton is a well-managed women's prison that successfully adapted its regime post-Covid. While praised for its safe environment, estate improvements, and dedicated staff, it is significantly hampered by staff shortages, impacting regime delivery and key worker scheme consistency. The Board highlights concerns regarding funding for essential facilities, the management of complex prisoners, and the need for improved transport arrangements and oversight of disciplinary processes.
PRISON
Key concerns
Cookham Wood (2021)
HMYOI Cookham Wood operated with a restricted regime during the reporting year due to Covid-19, leading to boys being locked in their rooms for extended periods and a significant reduction in purposeful activity and education. Staff shortages exacerbated these issues, though staff dedication and the transformation of the resettlement team were noted positives. Key concerns include the continued lack of secure mental health beds, delays in transferring 18+ year-olds, and inadequate IT facilities, all contributing to an environment the IMB deemed detrimental to the boys' wellbeing and development.
PRISON
Key concerns
Downview (2022)
HMP/YOI Downview experienced another year significantly impacted by the Covid-19 pandemic, leading to a restricted regime and challenges across various departments. While the Board found the prison safe and prisoners treated fairly, it raised significant concerns regarding the management and provision of healthcare, staffing pressures, and the lack of digital access for education. These issues highlight the ongoing difficulties in maintaining optimal conditions and services for prisoners under pandemic and resource constraints.
PRISON
Key concerns
Belmarsh (2022)
HMP Belmarsh experienced a challenging reporting year with improvements in health and wellbeing provision and a commitment to safety, though HMIP noted safety had deteriorated. The prison addressed equality and diversity issues through dedicated leadership and improved data, but concerns remain regarding disparities in outcomes for protected characteristics. Staffing issues, particularly high ‘non-effectives’ despite target numbers, curtailed regimes and impacted key worker compliance, while lost property and prolonged mental health transfer waits persisted as significant and repeated concerns.
PRISON
Key concerns
Chelmsford (2022)
HMP Chelmsford, a category B local prison, showed mixed performance in the reporting year ending August 2022. While levels of violence and self-harm decreased, and there were no deaths in custody, significant concerns persist regarding overcrowding (49% of prisoners sharing single cells) and long-standing issues with lost prisoner property. Staff shortages heavily impacted healthcare appointments, purposeful activity, and key worker effectiveness, contributing to many prisoners spending extended periods locked in cells.
PRISON
Key concerns
Isis (2022)
HMP/YOI Isis, a training prison for young adults and Category C men, housed around 600 prisoners in 2022. The Board noted an encouraging drop in self-harm and decreasing trends in violence and use of force, alongside effective healthcare leadership. However, significant concerns remain regarding persistent staffing shortages, insufficient time out of cell, and poor provision of purposeful activity and accredited rehabilitation programs, which hinder prisoners' progression and resettlement.
PRISON
Key concerns
Frankland (2022)
HMP Frankland, a high-security training prison, has operated near its 852 capacity. The Board noted positive developments including staff efforts to maintain safety, the continuation of social video calls, and strong educational engagement. Key concerns include chronic healthcare staffing shortages, persistent issues with property tracking, the ingress of illicit drugs, and the impact of heating problems on workshop availability.
PRISON
Key concerns
Hindley (2022)
HMP/YOI Hindley was deemed a safe environment with reduced violent incidents, but persistent staffing shortages led to extended lockdowns, negatively impacting prisoner wellbeing and mental health. The Board noted an increase in use of force and concerns over delays in parole hearings and inquests. While healthcare was satisfactory, low purposeful activity engagement and a lack of a clear incentives scheme remain significant issues.
PRISON
Key concerns
Lowdham Grange (2023)
HMP Lowdham Grange experienced a challenging reporting year (Feb 2022 – Jan 2023) marked by significant contract transition and refurbishment works. This led to a deterioration in safety, increased self-harm and assaults, and a decline in staff morale and prisoner engagement. Despite some positive healthcare developments like a new wellbeing centre, services remained below community standards, compounded by staffing shortages.
PRISON
Key concerns
Full Sutton (2022)
This report for HMP Full Sutton (Jan-Dec 2022) highlights persistent staff shortages, which led to regime lockdowns and reduced time out of cell. Despite these challenges, the prison maintained a safe and humane environment, showing improvements in education and complaint handling. Key concerns include drug testing levels, inconsistent equalities meetings, and the ongoing development of the STEP unit, with a shortfall in psychological and nursing staff also noted.
PRISON
Key concerns
Garth (2022)
HMP Garth, a Category B training prison, grapples with severe staff recruitment and retention issues, resulting in a largely inexperienced workforce and an ineffective key worker scheme. The restrictive regime, a consequence of staffing problems and post-pandemic recovery, limits prisoners' time out of cell and access to purposeful activity. Key concerns include the deteriorating estate, inadequate provisions for disabled individuals, and the persistent challenges faced by IPP prisoners, alongside ongoing issues with property transfers and an understaffed Offender Management Unit.
PRISON
Key concerns
Lewes (2023)
HMP Lewes continues to face severe challenges, primarily driven by staff shortages that restrict the regime, leaving many prisoners out of cell for only an hour a day. This has contributed to significant increases in self-harm and assaults on staff, while issues with healthcare provision, mental health support, and the decency of accommodation persist. The Board highlights the disproportionate use of force against BAME prisoners and the ongoing lack of resettlement support for those on remand.
PRISON
Key concerns
The Mount (2023)
HMP The Mount faced a challenging year ending February 2023, marked by a severe drug crisis involving Fentanyl-laced Spice, resulting in nine deaths, five of which were drug-related. Persistent staffing shortages led to a restrictive regime, limiting prisoners' access to education, work, and purposeful activity. Key concerns included overcrowding from cell doubling, significant healthcare waiting times exacerbated by escort shortages, and a failure to deliver adequate resettlement and offending behaviour programmes, contributing to an increase in prisoner complaints.
PRISON
Key concerns
Onley (2023)
HMP Onley, a Category C training and resettlement prison, faced significant challenges primarily due to persistent officer staff shortages during the reporting year. These shortages severely impacted the daily regime, key work delivery, access to education and workshops, and overall purposeful activity, leading to prisoners spending prolonged periods in their cells. The Board also raised concerns about illicit substances, food quality, and delays in prisoner property, while commending positive staff-prisoner relationships and efforts in resettlement and employment on release.
PRISON
Key concerns
Rochester (2023)
HMP/YOI Rochester maintained a stable and safe environment despite ongoing staff shortages, which impacted the regime for much of the year. While staffing improved by year-end, concerns persist regarding dilapidated buildings, property losses, and the availability of illicit drugs. The Board noted good mental healthcare provision and staff-prisoner relationships but raised significant concerns about the lack of suitable accommodation for released prisoners and the low education attendance rates.
PRISON
Key concerns
Send (2023)
HMP Send is a closed women's prison that made significant efforts to ensure prisoner safety and humane treatment during a challenging year. While the Board noted positive staff-prisoner relationships, persistent staff shortages, particularly in OMU and probation, negatively impacted services and progression. Key concerns include high self-harm rates, the lack of digital in-cell technology, the unjust detention of IPP prisoners, and property issues during transfers.
PRISON
Key concerns
Swaleside (2023)
HMP Swaleside experienced an unprecedented year of staff shortages, severely impacting the regime and humane treatment of prisoners with restricted time out of cell. Despite these challenges, the Board commends the SLT and staff for implementing an improving regime, which saw a decline in violence and self-harm incidents. Key concerns remain around staff retention, the poor state of facilities, long segregation times, inadequate resettlement support, and the high number of deaths in custody.
PRISON
Key concerns
Lancaster Farms (2023)
HMP Lancaster Farms, a category C resettlement prison, has largely provided a safe environment, though some pandemic regime restrictions were slow to lift. While primary healthcare is reasonable, mental health provision faces significant challenges due to staffing and a lack of specialist transfer capacity. Key worker contact and prisoner property management remain ongoing concerns for the Board, alongside issues of cell decency and delayed purposeful activity opportunities.
PRISON
Key concerns
Styal (2023)
HMP/YOI Styal faced significant challenges during the reporting year, primarily due to staffing shortages that compromised safety, regime consistency, and access to essential services. The prison recorded high rates of assaults and self-harm, often linked to an unpredictable daily routine. Despite these issues, the Board noted positive staff-prisoner relationships, improvements in induction and MBU facilities, and Styal's leading performance in employment outcomes for women on release.
PRISON
Key concerns
Pentonville (2023)
HMP Pentonville, a Category B local prison, faced significant challenges in 2022-2023, primarily due to overcrowding, antiquated facilities, and staff shortages impacting the regime and key work scheme. While the prison achieved notable successes in disrupting contraband and establishing a Neurodiversity Unit with positive outcomes, concerns persist regarding vulnerable prisoner safety, low time out of cell, and minimal resettlement support for its large remand population. Healthcare services showed improvements in patient access and staffing, but overall infrastructure and staffing levels continue to hinder humane conditions and effective rehabilitation.
PRISON
Key concerns
Isle of Wight (2022)
HMP Isle of Wight experienced a challenging 2022, marked by a population increase and the gradual easing of Covid restrictions, which allowed for a return to some normal regime activities. However, chronic staff shortages significantly hampered access to work, education, and healthcare, leading to prisoners spending considerable time locked up. The Board raised serious concerns regarding the inadequacy of mental health provision, the impact of staff shortages on all aspects of prison life, and the need for clarity and funding for the estate and the management of the Category C prisoner population.
PRISON
Key concerns
Stafford (2023)
HMP Stafford, a Category C training prison, generally provides safe and humane treatment, with significant improvements in medicines management. However, the report highlights critical issues, including the long-standing and hazardous state of prison roadways, which poses a serious safety risk. Persistent staff shortages continue to disrupt the regime, leading to lost activities, and a self-inflicted death involving an IPP prisoner raised serious questions. Additionally, concerns were noted regarding security compliance, reduced library services, and service delivery from the new visits management contractor.
PRISON
Key concerns
Stoke Heath (2023)
HMP/YOI Stoke Heath, a Category C training and resettlement prison, experienced an increase in self-harm incidents and near misses, alongside a noticeable rise in illicit items. While overall violence remained low, prisoners spent more time in their cells due to staffing shortages and inadequate purposeful activity, impacting sentence progression. Healthcare provision was generally met, though dental waiting times were long and planned mental health interventions limited. The Board highlighted concerns regarding prisoner property, resettlement support, and the need for more varied education and work opportunities.
PRISON
Key concerns
Nottingham (2023)
HMP/YOI Nottingham experienced a reduction in self-harm and use of force, but assaults on both prisoners and staff increased. Key challenges included inadequate provision for prisoners with severe mental health issues and disabilities, significant healthcare staff shortages, and concerns over the complaints system and property loss. The report also highlighted regime curtailments due to staff training and uncertainty for IPP prisoners.
PRISON
Key concerns
Portland (2023)
HMP/YOI Portland demonstrated a well-controlled environment with positive staff-prisoner relations and good physical facilities during the reporting year ending March 2023. However, the Board highlighted significant challenges in mental health provision due to staffing shortages, a fragmented resettlement program, and persistent issues with property delays. Recommendations focused on better funding for resettlement, improved communication regarding property, and prioritising key work to support prisoner wellbeing and progression.
PRISON
Key concerns
The Verne (2023)
HMP The Verne maintains a generally safe and respectful environment, successfully implementing a new self-harm monitoring system and demonstrating strong staff-prisoner relationships. The Board commends the high-quality physical healthcare provision, including excellent vaccination rates, and welcomes the establishment of a new 16-room social care unit aimed at addressing the long-standing concern for elderly and frail prisoners. However, significant challenges persist, particularly in resettlement provision, severe understaffing in the Offender Management Unit leading to backlogs, and long waiting times for mental health services and external healthcare appointments due to staff shortages.
PRISON
Key concerns
Feltham (2023)
Feltham, comprising a YOI (A side) and a Cat C prison (B side), faced significant challenges in the reporting year ending August 2023, primarily due to severe staff shortages impacting regime delivery, time out of cell, and purposeful activity. While staff were commended for their dedication, these shortages led to increased incidents on A side and curtailed essential services and rehabilitative programs across both sides. Key concerns also included the inadequate education provision for separated young people, safety in communal showers on B side, and the ongoing issue of lost prisoner property.
PRISON
Key concerns
Wormwood Scrubs (2023)
HMP Wormwood Scrubs faced significant challenges during the reporting year, including overcrowding and acute staffing shortages, which adversely impacted safety, regime delivery, and healthcare provision. Many prisoners spent extended periods locked in their cells with limited purposeful activity. Concerns persist regarding mental health transfer delays, an antiquated estate unsuitable for disabled prisoners, and poor food quality, though positive efforts in induction, reading support, and some service improvements were noted.
PRISON
Key concerns
Parc (2023)
HMP/YOI Parc reported eleven deaths in custody and a substantial increase in illicit item finds during the reporting period. The Board noted significant issues with inadequate mental health provision, excessive waiting lists for appointments, and critical staffing shortages impacting key worker sessions, healthcare, and education. Concerns were also raised about the quality and quantity of food, ineffective complaints handling, and the anxiety experienced by IPP prisoners due to release uncertainty. Positively, self-harm and violence incidents saw significant reductions.
PRISON
Key concerns
Bronzefield (2024)
Bronzefield faced significant challenges in the reporting year, primarily due to severe staff shortages impacting all aspects of the regime, leading to prisoners being locked up for extended periods and missing activities. Healthcare delivery was suboptimal due to lack of staff and poor coordination, resulting in medication delays and cancelled appointments. The prison also grappled with a high incidence of self-harm and challenges in managing complex, mentally unwell prisoners, compounded by external bed shortages.
PRISON
Key concerns
Feltham (2024)
HMP/YOI Feltham faces significant challenges, particularly high staff absence severely impacting regime delivery and time out of cell for both young people and adults. The physical environment is in a poor state, with persistent issues like leaking roofs and mould, alongside a worrying increase in violence, including staff assaults on Feltham B, and a rise in contraband finds. While healthcare provision is generally good and staff are commended for their dedication, the lack of purposeful activity, effective key worker sessions, and the closure of the Enhanced Support Unit hinder rehabilitation and overall prisoner wellbeing.
PRISON
Key concerns
Brinsford (2024)
HMP Brinsford, a resettlement prison for young men (18-22 with temporary extension to 29), operates at full capacity of 577, with an average population of 529. The report highlights improvements in self-harm reduction and healthcare provision, but raises significant concerns about low staffing levels impacting safety, the ongoing increase in violence, and the critical lack of purposeful activity places. There are also persistent issues with infrastructure, property management, and delays in transferring prisoners with severe mental health needs.
PRISON
Key concerns
Liverpool (2024)
HMP Liverpool, a Category B reception prison, continued to improve in some areas under new leadership despite persistent staffing challenges. Concerns escalated regarding prisoner safety, including increased self-harm, violence, and use of force, alongside significant delays in mental health transfers and regime delivery. The prison also struggles with the entry of illicit items and maintenance issues with its Victorian infrastructure.
PRISON
Key concerns
Isle of Wight (2024)
HMP Isle of Wight saw a less safe environment in 2024, with significant increases in assaults, self-harm, and use of force, largely attributed to rising drug availability and staffing pressures, especially among probation and mental health teams. Key concerns include a lack of secure hospital beds for mentally ill prisoners, long healthcare waiting times, and issues with the regime, including poor laundry facilities and food service. The Board highlights improvements in education attendance, neurodiversity support, and some aspects of reception and induction, while also noting repeated recommendations regarding mental health transfers and probation staffing remain unaddressed.
PRISON
Key concerns
Swinfen Hall (2025)
HMP Swinfen Hall continued to struggle, delivering reduced outcomes for young adults despite considerable efforts by the leadership. The prison is under-resourced, leading to safety concerns, staff confidence issues, and frequent weekend wing closures. Key areas like purposeful activity, staff-young adult relationships, and the paper-based application system remain inadequate. While some security improvements were noted, the overall regime and support for complex needs, including neurodiversity, require significant development.
PRISON
Key concerns
Winchester (2025)
HMP/YOI Winchester continues to face significant challenges including persistent overcrowding, staffing pressures, dilapidated infrastructure, and high levels of self-harm and violence. Despite these issues, the Board notes staff professionalism and adaptive responses, particularly in addressing the HMIP Urgent Notification. The prison is making positive efforts towards improvement, with some progress in repairs and adapting the regime, though key concerns like illicit substance ingress and healthcare provision persist.
PRISON
Key concerns
Fosse Way (2025)
HMP Fosse Way faced significant operational challenges in its second year, including high prisoner churn, staffing shortfalls, and persistent building deficiencies like unsuitable furniture and failing lifts. Healthcare provision was unstable, with cancelled appointments and no overnight service, compounded by delays in mental health transfers. While purposeful activity and vocational training were praised, many places remained unallocated, and drug finds were a continued concern.
PRISON
Key concerns
Bedford (2025)
HMP/YOI Bedford, a Category B reception and resettlement prison, continues to face challenges with overcrowding, high levels of violence, and pervasive illicit item use. While some improvements have been made in reception and living conditions, the healthcare service is under significant strain, evidenced by a CQC warning notice. The Board also highlights concerns regarding staff retention (due to visa issues), a limited education curriculum, and an antiquated paper-based system for property and complaints.
PRISON
Key concerns
Bronzefield (2025)
HMP/YOI Bronzefield, a women's local and YOI prison, reported a population of 506 and a CNA of 5271. While some progress was noted in leadership and property management, the report highlights significant concerns regarding healthcare delivery, staffing pressures, and the impact of roll-counts on the regime. Mental health services remain strained, and issues with food provision, complaint handling, and resettlement support persist, many of which were repeated from previous years.
PRISON
Key concerns
Featherstone (2024)
HMP Featherstone faced challenges including the dilapidated state of its facilities, persistent issues with property management, and stretched healthcare services, particularly for mental health. However, the Board observed improvements in staffing levels, education provision, and reduced waiting times for doctors and dentists. Key concerns remain around the prison's aging infrastructure, the treatment of mentally unwell prisoners in segregation, and inconsistent staff culture.
PRISON
Key concerns
Cardiff (2025)
HMP Cardiff saw a significant reduction in self-harm, use of force, and violence incidents this year, alongside positive developments like the Launchpad project and improved GP services. However, the Board remains concerned about persistent issues such as severe staffing shortages in healthcare, particularly nursing and pharmacy, and delays in mental health transfers. Prison conditions, including heating, water, and accessibility, continue to be problematic, and the key worker scheme needs greater prioritisation amidst ongoing population pressures.
PRISON
Key concerns
Onley (2020)
HMP Onley experienced a challenging year with a restricted regime, largely due to staffing shortages, though improvements were seen towards the end. Key concerns include significant issues with property transfers, a dysfunctional complaints process, and a lack of purposeful activity leading to prisoners spending extended periods in their cells. The Board highlights persistent problems with resettlement progression, including missing OASys reports and slow transfers, alongside concerns about drug availability, self-harm incidents, and the general state of the estate. While staff-prisoner relationships improved and the OMiC model showed promise, the report calls for urgent action on staffing, regime provision, and inmate progression.
PRISON
Key concerns
Cardiff (2020)
HMP Cardiff maintained a reasonably safe environment with low violence, but self-harm incidents increased to 712, with four deaths in custody (three self-inflicted). The COVID-19 pandemic severely restricted the regime, impacting purposeful activity, time out of cell (1.5 hours daily), and overall prisoner wellbeing. Persistent staffing shortages hampered healthcare and mental health services, while disparities for BAME prisoners in areas like segregation and dangerous prisoner labels remained a concern.
PRISON
Key concerns
Erlestoke (2021)
HMP Erlestoke generally maintained a safe and humane environment during the reporting year ending March 2021, despite the challenges of Covid-19. Key improvements included a significant reduction in violence, commendable healthcare management of a Covid-19 outbreak, and improved resettlement planning. However, concerns remain regarding a troubling increase in self-harm, inadequate provision for prisoners with complex needs and IPP sentences, estates issues, and the impact of regime restrictions on purposeful activity.
PRISON
Key concerns
Bullingdon (2021)
HMP Bullingdon faced significant challenges during the reporting year (July 2020 – June 2021), exacerbated by Covid-19 restrictions which led to extensive in-cell time and impacted various services. The Board noted chronic overcrowding, an increase in self-harm incidents, and persistent issues with staff experience levels and the provision of mental healthcare. Progression and resettlement efforts were hindered by a high turnover of prisoners, predominantly those on remand or serving short sentences, while the effectiveness of drug interception measures remains a concern.
PRISON
Key concerns
Elmley (2021)
HMP Elmley experienced a challenging year ending October 2021 due to its status as a COVID-19 outbreak site, leading to highly restricted regimes and persistent staffing shortages. The Board noted positive initiatives like the Accelerator project and OMU surgeries, but raised significant concerns regarding prolonged confinement, inadequate food budget, and issues with property loss and unlock list management. The report highlights critical needs for improved staff recruitment and retention, better analysis of self-harm incidents, and a review of external service contracts.
PRISON
Key concerns
Hull (2022)
This report for HMP Hull, ending February 2022, highlights a challenging period marked by the ongoing impact of Covid-19 restrictions, which limited IMB monitoring capacity and led to significant staff absences. While safety metrics showed reductions in violence, self-harm, and use of force, serious concerns remain regarding healthcare provision, which was deemed failing by HMIP and led to contract termination. Other critical issues include insufficient cell capacity, restricted key worker support, and ineffective resettlement pathways due to poor external agency communication.
PRISON
Key concerns
IMB individual recommendations(61)— showing 50 strongest matches
Foston Hall (2021)
The IMB is concerned about: staffing pressures in healthcare and mental health, impacting on services provided.
Governor / Director
Cardiff (2021)
The second has been raised by the temporary clinical director who has identified the need for increased GP hours to cover the health needs of the men.
NHS / Healthcare Provider
Implemented
Cardiff (2021)
The Board has two concerns in relation to healthcare which we would ask the Health Minister to consider with Cardiff and the Vale Health Board. Both relate to staffing: the first is the ongoing issue with lack of cover for pharmacists, which can lead to locum pharmacists being brought in on an emergency basis and affects the planning of the …
NHS / Healthcare Provider
In Progress
Lowdham Grange (2022)
To exert pressure on the commissioners of Nottinghamshire Healthcare NHS Trust to secure and maintain staffing at a level to provide the service required for all prisoners’ health and wellbeing needs.
Governor / Director
Frankland (2022)
What plans does the Ministry of Justice (MOJ) have to address the chronic staffing shortages in healthcare?
Ministry of Justice
Bronzefield (2024)
How does NHS England plan to address the shortage of GPs, nurses, and substance misuse practitioners in Bronzefield? (6.1, 6.5)
NHS / Healthcare Provider
Heathrow Immigration Removal Centre (2021)
The healthcare manager’s efforts to achieve full staffing should continue to be supported, especially in the area of mental health, which is seriously understaffed.
NHS / Healthcare Provider
Downview (2021)
Provide support to enable prompt recruitment to critical psychology intervention roles to address reduced capacity, headcount, and waiting lists, particularly during a time of increased demand.
HMPPS
Implemented
Isle of Wight (2022)
recognising the staffing challenges, the Mental Health Department needs to be brought up to establishment strength.
Governor / Director
Heathrow Immigration Removal Centre (2022)
The Healthcare Manager’s efforts to achieve full staffing should continue to be supported, especially in the area of mental health, which is seriously understaffed.
NHS / Healthcare Provider
Foston Hall (2022)
The lack of available clinical staff at night-time on occasion (see paragraph 6.2.3)
Governor / Director
Usk and Prescoed (2024)
When will the Minister review the healthcare staffing establishment so that it reflects the changing case mix and planned expansion?
Ministry of Justice
In Progress
Oakwood (2024)
The Board is concerned that there are ongoing recruitment and retention issues for staff working in prison mental health services when the demand is increasing. There is still a vacancy for a psychologist at HMP Oakwood and a number of roles are being covered by agency or bank staff. What does the Minister plan to do to improve this situation?
Ministry of Justice
In Progress
Nottingham (2024)
To address with the health care provider the continuing shortcomings in the service provided, in particular the staff shortages and the lack of a deputy.
Governor / Director
Deerbolt (2024)
The Board urges HMPPS to visit Deerbolt, meet the healthcare team, urgently review the staffing model and support additional resources clearly needed to meet the demands from the establishment.
HMPPS
Portland (2020)
The provision of healthcare services has suffered for lack of a psychologist and psychiatrist at times during the reporting period. The appointment and retention of psychologists and psychiatrists to posts in Portland have been problematic since the contract transferred from the local health authority. It would be helpful if the reasons for this could be explored and, where possible, addressed.
Governor / Director
Lindholme (2020)
Will the Prison Service consider what measures are needed to ensure that the staffing levels of the healthcare provider are maintained as per contract (see section 8)?
HMPPS
In Progress
Leeds (2020)
Is the Governor able to support the healthcare team in their request to the NHS for another nurse to work as part of the reception team?
Governor / Director
Dover (2020)
The medical provision in the holding rooms should be expanded to ensure permanent access to more than one medical professional at busier times. The expansion to 24 hours per day was achieved just after the end of the reporting period; however more than one medic should be available.
Other
Gartree (2021)
The Board acknowledges the Minister’s response to the question raised in our last annual report regarding the national partnership agreement for prison healthcare. The Board requests the Minister provide a further update on resources being planned post-Covid-19 to enable the delivery of measures outlined in the partnership agreement specifically for Gartree, as the Board has increasing concerns regarding the mental …
Ministry of Justice
Usk and Prescoed (2022)
a replacement appointment is urgently needed.
NHS / Healthcare Provider
In Progress
Send (2022)
Recruitment issues continue to impact on all areas of prison life including operational staff, healthcare and catering (3.1, 5.1, 6.1, 6.2).
HMPPS
In Progress
Isle of Wight (2022)
Efforts should also be made to prioritise staffing to escort prisoners for health care appointments.
Governor / Director
Hewell (2022)
Healthcare contracts should be reviewed to ensure that there is safe out-of-hours cover; this will improve the health, safety and wellbeing of prisoners, reduce the number of staff hours needed to escort men to outside provision, and reduce the pressure on already overstretched ambulance and NHS resources.
NHS / Healthcare Provider
Noted
Ashfield (2022)
Can the Minister raise with the Secretary of State for Health and Social Care the Board’s concerns that healthcare resource shortages (both physical and mental health) in a prison environment are putting the wellbeing of prisoners at risk?
NHS / Healthcare Provider
Oakwood (2023)
The Board is concerned that there has been a vacancy for a Psychologist for the duration of the reporting period. A campaign to recruit a Psychologist is ongoing but reports indicate that recruitment is difficult, with too few Psychologists who are either available or willing to work within a prison environment. The career pathway, training and recruitment of Psychologists should …
Other
Wandsworth (2024)
With the current staff shortages, will it be possible to operate the new healthcare centre safely?
Governor / Director
Featherstone (2024)
Issues with low numbers of healthcare staff have, on occasion, meant that the regime has been disrupted because of delays dispensing medication. This has been an ongoing issue and consideration should be given as to whether the system can be changed to increase its reliability and consistency.
Governor / Director
Bronzefield (2024)
NHS England specifies the provision of face-to-face GP services, seven days a week. However, to date, this has not been achieved. How and when does NHS England intend to remedy this lack of provision? (6.1)
NHS / Healthcare Provider
The Verne (2025)
Will HMPPS consider funding 24-hour on-site clinical cover at the Verne, provided by a nurse or paramedic? (See 6.5.2)
HMPPS
Rejected
Dovegate (2025)
The demand for specialised provision for prisoners with mental health and/or personality disorders needs remains higher than the provision available. Will the Prison Service create a structured plan to increase both spaces and staff to support them, with clinical staff as well as administrative?
HMPPS
In Progress
Bronzefield (2025)
How does NHS England plan to address the shortage of experienced nurses in Bronzefield (6.1, 6.5)?
NHS / Healthcare Provider
In Progress
Yarl’s Wood (2020)
The Board recommends that NHS England maintains the excellent staffing levels and services of the last year.
NHS / Healthcare Provider
Long Lartin (2020)
Recruitment of healthcare staff continues to be hampered by the extremely slow vetting process.
HMPPS
Noted
Foston Hall (2021)
The IMB is concerned about: the ongoing absence of initial screening of prisoners for learning difficulties and disability (LDD) due to a staffing shortage.
Governor / Director
Foston Hall (2021)
The IMB is concerned about: the ‘short-term’ closure of the mental health office to facilitate the demolition of A and B wings, which by November had extended into three months, causing acute problems for the delivery of mental health services
Governor / Director
In Progress
Yarl’s Wood (2022)
The Board recommends that NHFT continues to maintain the excellent staffing levels and services of the last year.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available on, a 24/7 basis, to provide detained individuals with necessary physical and mental healthcare.
NHS / Healthcare Provider
Gatwick, Stansted, Luton and Lunar House (2022)
at Gatwick, Luton, and Stansted airports, dedicated medical practitioners should be available on, a 24/7 basis, to provide detained individuals with necessary physical and mental healthcare.
Other
Bedford (2022)
Mental health services in the prison are poor. This is mainly due to staff shortages. We request that the minister review budgets for mental health staff especially in local prisons.
Ministry of Justice
Usk and Prescoed (2023)
Access to specialist mental health facilities remains a problem as the team struggled with low staff numbers.
Ministry of Justice
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Erlestoke (2023)
What action is being taken to ensure that additional healthcare facilities and staff will be provided when the prison’s operational capacity increases?
HMPPS
Wormwood Scrubs (2024)
What further steps will be taken to accurately monitor and reduce the number of therapy and healthcare sessions not attended because of the lack of prison staff (see section 6)?
Governor / Director
Fosse Way (2025)
As identified in 3.1, the health-care provision for getting prisoners to hospital on booked appointments had been erratic and resulted in a number having to be cancelled. Whilst appreciating that staff shortages, bed watches and EE (emergency escorts) are a major contributor to this situation, how will the Director ensure prisoners receive the necessary treatment at the appointed time?
Governor / Director
In Progress
New Hall (2020)
Healthcare provision should be consistently delivered and sufficient staffing levels maintained to ensure the safety and well-being of prison staff and residents alike.
Governor / Director
In Progress
Durham (2020)
How can the allocation of officers to the inpatient healthcare centre be made sustainable?
Governor / Director
Yarl’s Wood (2021)
The Board recommends that NHFT continues to maintain the excellent staffing levels and services of the last year.
NHS / Healthcare Provider
Hull (2021)
Improve the management structure of healthcare provision and its communication with prison management.
Governor / Director
Health investigations(130)
An independent investigation into the care and treatment of a … — Rec Recommendation 5
The Trust should ensure that there is dedicated and consistent medical cover available in all areas that Early Intervention in Psychosis provide a service.
south_east
An independent investigation into the care and treatment of a … — Rec R6
For there to be dedicated and consistent medical cover available in all areas that Early Intervention in Psychosis provide a service.
south_east
Independent investigation report into the care and treatment of Yusuf — Rec 3
Medical staffing levels were below expected levels on the night of 15 November. • The Trust should assess medical and nursing staffing levels in the paediatric UECC overnight to ensure capacity meets demand. This should include the number of clinicians, their seniority and their level of paediatric experience. • The …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
The new Suffolk Health Authority should review whether the availability of forensic psychiatry services is sufficient.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
Purchasers of social care should ensure that an adequate supply of forensic social work is available in their area.
east_of_england
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.ii.d
Consideration should be given to the appointment of a Nurse Consultant with a particular focus on inpatient services in Bury.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.i.e
Whilst we understand the pressures on the time of the Medical Director, we believe that until it is possible to appoint new Consultants to Bury, there will need to be time set aside to become more involved in the services in Bury. We cannot find evidence that the situation with …
north_west
Independent investigation: Asiya Khatun, Newham (2000) — Rec 1
East London and The City Mental Health NHS Trust should make every effort to secure permanent appointments to consultant psychiatrist posts so as to enable continuity in care, the consistent development of policies and procedures, and consistent implementation of the National Service Framework for Mental Health.
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 6
The staffing levels on Darwen ward should be reviewed to reflect the need for planned therapeutic activity.
north_west
Independent investigation: Valerie Thomas, Cardiff (2005) — Rec 6
A review of the staffing made available to the CMHTs within Cardiff and Vale NHS Trust should be undertaken. In particular the number of medical, nursing and social work staff and the provision of a broader range of support staff and services should be considered. The guidelines referred to in …
wales
Independent investigation: Tom Easton, Old St, London (2006) — Rec 1
The ELFT should undertake a joint strategic needs assessment of the population of each CMHT catchment area and link this to a review of the workload of each of the four CMHTs to determine the actual workload of each and then adjust the staffing to better reflect the known needs …
london
Independent investigation: Tina Stevenson&2 babies, Hull (2005) — Rec 19.8
There should be a review of the staffing levels available at the unit visited by the Team which now manages without the support of the CMHT staff once located within the building. The MH Trust Board should assure itself that this facility is a safe environment for both patients and …
north_east_yorkshire
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 5
That the Children and Family Court Advisory Support Service (CAFCASS) is encouraged and enabled to: - a) arrest the decline in the number of Children’s Guardians; b) encourage suitably experienced people to continue in and take on this work; c) ensure that adequate funding is authorised for particularly complex cases; …
south_east
Independent investigation: Simon Sutton, Birkenhead (2007) — Rec R6
The trust should ensure that they have the appropriate number of consultant psychiatrists in post - in line with the Royal College of Psychiatrists’ guidelines. If necessary, a review of locum staff use should be conducted.
north_west
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 21
The Trust requires the services of trained family therapists. Clinical psychologists and social workers can provide assessments, some treatments, and supervision for other professionals in the CMHTs.
south_east
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 12
There is an urgent need for the Trust to fund psychology posts and ensure that psychologists have a role in the CMHTs.
south_east
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 3
Where it is not possible to fill consultant posts with adequately qualified and otherwise suitable psychiatrists, locums and others acting as consultants should receive regular and recorded supervision under the oversight of the medical director.
south_east
Independent investigation: Rae Torbet(Ms E), Hastings, Sussex (2003) — Rec 9.6.1
that the team has sufficiently resourced Consultant Psychiatrist input.
south_east
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 7
The workload of consultant psychiatrists should be regularly monitored to ensure that they are not being spread too thinly across too many areas of responsibility. This should be linked to the Clinical Audit Programme and routinely reviewed.
south_west
Independent investigation: Michael Galloway, Illingworth (1999) — Rec 6.8
The panel recommends that the Trust and the commissioners of service consider the recruitment of substantive consultant cover.
north_east_yorkshire
Independent investigation: Melanie Welch (Ms B), Redhill, Surrey (2001) — Rec 7.5
We recommend:- That the Trust initiates a debate amongst its senior clinicians to review their roles within the organisation and with clinical teams. Part of this review must include workload and numbers of consultants, with reference to the Royal College of Psychiatrists’ guidelines.
south_east
Independent investigation: Margaret Ford, Templeton, Pembs (2009) — Rec 4
In relation to the function of the CMHT and CRHT, Hywel Dda Health Board and, where appropriate, Pembrokeshire County Council should: • Review the availability and implementation of clinical and managerial supervision to ensure that staff are appropriately supported. • Look to improve staffing levels in both teams. • Ensure …
wales
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 11
NHS organisations should be alert to the inherent risks of a long period with a shortage of senior medical staff, or a rapid turnover of such staff. In such circumstances the Human Resources Strategy should ensure that the caseload in psychiatric outpatients is reviewed to make certain that all cases …
east_of_england
Independent investigation: Lesley Wright, Tooting (2006) — Rec R6
The trust should ensure that operational managers monitor the impact of sickness absence and take action to minimise its effect on the functioning of CMHTs.
london
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008) — Rec 3.4n
Ensure that medical support arrangements are put in place in relation to the CRHT.
wales
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 4a
Undertake a review of the resources allocated to each of their CMHT’s, ensuring that they are equitably, and adequately resourced taking into account the population and morbidity for each CMHT area5.
wales
Independent investigation: John McGrath, Stapleford, Nottingham (2009) — Rec 2
If the current model of AO is to continue in Nottinghamshire, it is essential that there is an increase in the provision for dedicated medical sessions to the County South AO Team. This investigation, and the Trust’s own investigation, identified insufficient medical sessions provided to this AO Team. This means …
midlands
Independent investigation: Jayne Poppy, Leigh on Sea (2002) — Rec 17
The Trust should ensure that there is a system in place for ensuring that the Trust carries out a further investigation into the robustness of medical care at the time of the December 2002 incident, covering the point of a shortage of substantive Consultants or of suitable candidates for vacant, …
east_of_england
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 2
There should be adequate social work resources available to support the implementation of Recommendation 1.
midlands
Independent investigation: Eric Daggers, Croydon (2005) — Rec 11
The trust should consider a review of the caseload and staffing levels in the Croydon Forensic Team. (DB)
london
Independent investigation: Caroline WillsAshley Wills, Cramlington, North-umberland (2000) — Rec 11
Demonstrate that the recruitment and retention of dedicated and appropriately qualified staff at all levels with reasonable caseloads is prioritised.
north_east_yorkshire
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003) — Rec 8.4.16
The panel notes that the Caswell unit at Bridgend now has audio-visual communication technology which could be linked to west Wales, which would assist in achieving some of the other recommendations made here and may even act as an interim partial solution to the staffing shortage.
wales
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003) — Rec 8.4.5
Efforts should be made to ensure staffing (to include medical, nursing, psychology, and occupational therapy) in the mental health field is up to establishment level and that the establishment level is sufficient. This could take the form of a brief research programme to evaluate the causes of any deficiencies.
wales
Independent investigation: Camille Remy (pregnant), Hackney (2006) — Rec R1
The ELC NHS trust should keep the staffing levels of the SE CMHT under review to ensure that casework pressures do not adversely influence the way patients are managed and to ensure that individual caseloads are manageable and allow staff to fulfil all their professional obligations, including record-keeping, satisfactorily.
london
Independent investigation: Beatrice Hughes, Harrow (1997) — Rec b.
they should ensure that adequate resources (staffing levels, training and information systems) are made available to support the Modernised Care Programme Approach national policy guidance, and significantly improve implementation performance compared to 1991
london
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.4
HMP Parc should review its compliment of Registered Mental Health Nurses (RMNs) and ensure that levels are appropriate to enable timely and appropriate screening assessments to taking place at the prison mental health clinics.
wales
Independent investigation: Alan Geddes, Aberdeen (2019) — Rec 3
The Scottish Government’s national mental health workforce strategy should take full account of the individual impact of lack of continuity of care as highlighted in Mr TU’s case relating to recruitment and retention of consultant psychiatrists/senior medical staff in health boards.
scotland
William Mead – Root Cause Analysis Investigation Report — Rec a)
That NHS England SSW escalates to national bodies the issues relating to the pressure on primary care in relation to: antibiotic prescribing; referrals to secondary care; and workload.
south_west
*Independent investigation into the care of Mr A: March 2013 — Rec 8
CPFT should increase the level of access to a Consultant Psychiatrist available to the MHIRT in order to comply with National Guidelines at all times.
Cambridge and Peterborough NHS Foundation Trust
east_of_england
*Independent investigation into the care and treatment of Mr P: … — Rec 7
The Trust should ensure that within the Early Warning Trigger Tool, consistently high use of locum CMHT and medical staff is included as a potential warning for teams at risk of poor performance. For those teams where this occurs the Trust should ensure that the appropriate risk registers reflect the …
south_east
An independent review of the care and treatment received by … — Rec R2
The trust should assure itself that the level of qualified staff on the ward is sufficient, safe, and meets the needs of the patients. There should be arrangements to ensure that escalation processes function effectively to alert senior staff if qualified nursing levels are compromised because of sickness or vacancies.
north_east_yorkshire
An independent review of the care and treatment received by … — Rec R1
The trust should work with its health system partners to establish on-site seven-day-a-week senior medical cover for their inpatient acute services. This should include access to associated clinical services such as pharmacy, pathology and ECG. This would ensure that the best possible care and support is provided, and that the …
north_east_yorkshire
An Independent Review into the care and treatment provided by … — Rec 4
The Trust must work with its current and future workforce levels to recognise, adapt to and manage the safety challenges that a staffing shortfall may pose, including ensuring the stability of nursing staff. The Trust must develop a representative, competent and culturally sensitive workforce which is supported to provide services …
Greater Manchester Mental Health NHS Foundation Trust
north_west
An independent investigation into the care and treatment of ‘Rachel’¹: … — Rec 4
Whilst access to psychiatric cover by the EIS in an emergency is now provided (as at the time of the index offence) by consultants working in other teams or, depending on where the patient is registered, by the patient’s own consultant, consideration should be given to the provision of dedicated …
Rachel . At the time of the homicide (2014), Rachel was a mental health service user at Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An Independent Investigation into the care and treatment of Mr … — Rec 5
The Trust should ensure that appropriate processes are in place to agree contingency arrangements for staffing shortages.
midlands
An independent investigation into the care and treatment of mental … — Rec 4
The Trust should assure themselves and commissioners that arrangements are in place to provide appropriate medical cover on the acute adult in-patient wards to ensure medical oversight and continuity of care.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
An Assurance Review of the Independent Review into the care … — Rec 4
The Trust must work with its current and future workforce levels to recognise, adapt to and manage the safety challenges that a staffing shortfall may pose, including ensuring the stability of nursing staff. The Trust must develop a representative, competent and culturally sensitive workforce which is supported to provide services …
Greater Manchester Mental Health NHS Foundation Trust
north_west
An assessment of a mental health trust’s internal investigation of … — Rec R8
The Trust should undertake a comprehensive review of its staffing and capacity within community mental health services, particularly in relation to the management of complex cases, to assess the impact on service users’ diagnosis, treatment, and risk management. This review should inform workforce planning and resource allocation to ensure safe …
north_east_yorkshire
This Independent Investigation into concerns and issues raised relating to … — Rec 7
The Trust should review its current arrangements for on-call services in Urology, particularly at Furness General Hospital, to ensure adequate staffing levels, timely access to theatre space, and safe working practices for all staff.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
This Independent Investigation into concerns and issues raised relating to … — Rec 45
All NHS organisations should ensure that demand management and specialty development are proactively planned and managed, with clear strategies for workforce planning, skill mix, and the development of sub-specialties to meet the needs of the population.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Scottish Fatal Accident Inquiries(2)
Mark John Andrew Smith
However, on the basis that more information allows for a greater ability to make a good decision, the SPS and THB/NHS should consider whether to make it a mandatory requirement for nursing staff to check medical records (if they are available) for a prisoner at the reception assessment. (2) Mr Gilmartin has suggested that more information should be physically transferred …
Sep 2017
Freya Murphy
(i) In terms of section 26(4)(b) and (d) of the Act, that Greater Glasgow Heath Board (GGHB) should review staffing levels across all shifts to ensure that its labour wards, post-natal wards, maternity assessment units and other hospital maternity related areas are adequately staffed at the weekend and in the evening such as to allow, in the case of an …
May 2025
Independent reviews(47)
Mental Health Taskforce 2016 — Rec 32
HEE should work with NHS England, PHE, the Local Government Association and local authorities, professional bodies, charities, experts-by-experience and others to develop a costed, multi-disciplinary workforce strategy for the future shape and skill mix of the workforce required to deliver both this strategy and the workforce recommendations set out in …
Health & Social Care
Social Work Task Force — Rec 14
Recommendation 14: Social Worker Supply — The Social Work Task Force recommends a new system for forecasting levels of supply and demand for social workers.
Other
Wanless Review — Rec 6
NSFs should in future include estimates of the resources – in terms of the staff, equipment and other technologies and subsequent cash needs – necessary for their delivery (6.14).
Health & Social Care
Wanless Review — Rec 2
The NHS workforce planning bodies should examine the implications of this Review's findings for their projections over the next 20 years (3.82).
Health & Social Care
O'Neill AMR Review — Rec 7
Improve the numbers, pay and recognition of people working in infectious disease 7.1 Governments, healthcare system leaders and private actors (such as clinical professional bodies and academic institutions), should work together to expand funding and training opportunities to increase the number and capacity of healthcare workers on the frontline of …
Health & Social Care
Berwick Review — Rec 4
Government, Health Education England and NHS England should assure that sufficient staff are available to meet the NHS's needs now and in the future. Healthcare organisations should ensure that staff are present in appropriate numbers to provide safe care at all times and are well-supported.
Health & Social Care
Shaw Detention Review — Rec 52
Recommendation 52: As part of its response to future growth in the demand for healthcare, NHS England needs to ensure the filling of permanent healthcare vacancies in IRCs as a priority.
Immigration
Carol Black Drugs Review (Part 2) — Rec 9
We recommend that DHSC commission HEE to devise by the end of 2021 a comprehensive strategy to increase the number of professionally qualified drug treatment staff (psychiatrists and other doctors, psychologists and other therapists, nurses and social workers), and set occupational standards, competency and training requirements for drug workers and …
Health & Social Care
Morecambe Bay Investigation — Rec 21
The challenge of providing healthcare in areas that are rural, difficult to recruit to or isolated is not restricted to maternity care and paediatrics. We recommend that NHS England consider the wisdom of extending the review of requirements to sustain safe provision to other services. This is an area lacking …
Health & Social Care
Morecambe Bay Investigation — Rec 20
There should be a national review of the provision of maternity care and paediatrics in challenging circumstances, including areas that are rural, difficult to recruit to, or isolated. This should identify the requirements to sustain safe services under these conditions. In conjunction, a national protocol should be drawn up that …
Health & Social Care
Nurse RDI Review — Rec 17
There is an urgent problem with the current mechanisms for clinician scientists to effectively develop and undertake their research careers. The Government, taking into account devolved competencies, must rectify this to both improve the ability of the NHS to deliver more effective health care and to help the UK economy.
Other
Wessely Review — Rec 152
The factors that affect the timely availability of section 12-approved doctors and AMHPs should be reviewed and addressed.
Health & Social Care
Accepted
Darzi Review — Rec 25
Despite the challenges, the NHS's vital signs remain strong. The NHS has extraordinary depth of clinical talent, and our clinicians are widely admired for their skill and the strength of their clinical reasoning. Our staff in roles at every level are bound by a deep and abiding belief in NHS …
Health & Social Care
Darzi Review — Rec 23
It is apparent from this report and from the accompanying analysis that the NHS is in critical condition. It continues to struggle with the aftershocks of the pandemic. Its managerial capacity and capability have been degraded, and the trust and goodwill of many frontline staff has been lost. The service …
Health & Social Care
Darzi Review — Rec 20
Staff engagement. Too many staff are disengaged. There is also compelling evidence that, post-pandemic, too many staff have become disengaged, and there are distressingly high-levels of sickness absence – as much as one working month a year for each nurse and each midwife working in the NHS. The experience of …
Health & Social Care
Darzi Review — Rec 6
People are struggling to see their GP. GPs are seeing more patients than ever before, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is at its lowest ever level. There are huge and unwarranted variations in the number …
Health & Social Care
Darzi Review — Rec 1
The National Health Service is in serious trouble. The British people rely on it for the moments of greatest joy – when a new life comes into being – and those of deepest sorrow. We need it when we are suffering from mental distress or hurting from physical pain and …
Health & Social Care
Ockenden Review — Rec 12
Postnatal care. Essential action: Trusts must ensure that women readmitted to a postnatal ward and all unwell postnatal women have timely consultant review. Postnatal wards must be adequately staffed at all times. • All trusts must develop a system to ensure consultant review of all postnatal readmissions, and unwell postnatal …
Health & Social Care
Accepted
Ockenden Review — Rec 2
Safe staffing. Essential action: All trusts must maintain a clear escalation and mitigation policy where maternity staffing falls below the minimum staffing levels for all health professionals. • When agreed staffing levels across maternity services are not achieved on a day-to-day basis this should be escalated to the services' senior …
Health & Social Care
Accepted
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
Cass Review — Rec 13
To increase the available workforce and maintain a broader clinical lens, joint contracts should be utilised to support staff to work across the network and across different services.
Health & Social Care
Accepted
Acheson Report — Rec 38.4
We recommend establishing a review of the relationship of private practice to the NHS with particular reference to access to effective treatments, resource allocation and availability of staff.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 9
Urgent action is needed to support the nursing academic workforce and guarantee its future quality: halt the decline in numbers, raise morale, and attract new staff.
Health & Social Care
Tooke MMC Inquiry — Rec 22
Recognising i) the importance of linking workforce supply and demand, ii) the very recent devolution of workforce commissioning function to SHAs in England, we recommend that this situation prevails for the moment for initial Postgraduate Medical Training subject to the forging of closer links at all levels with the Higher …
Health & Social Care
Tooke MMC Inquiry — Rec 16
DH should recognise the burgeoning supply of medical graduates it has commissioned and make explicit its plans for the optimal use of their skills for the benefit of patients. It is recommended that sufficient numbers of Core Specialty training posts (see Recommendation 33) should be made available to accommodate doctors …
Health & Social Care
Tooke MMC Inquiry — Rec 12
DH Workforce should urgently review its medical workforce advisory machinery to ensure that it receives integrated and independent advice on medical workforce issues to inform/complement SHA and local deliberations. Both national and devolved workstreams must be adequately resourced. The medical workforce advisory machinery should also take account of national policies …
Health & Social Care
Tooke MMC Inquiry — Rec 11
DH should have a coherent model of medical workforce supply within which apparently conflicting policies on self-sufficiency and open- borders/overproduction should be publicly disclosed and reconciled. We recommend that overseas students graduating from UK medical schools should be eligible for postgraduate training as should refugee doctors with the right to …
Health & Social Care
Mental Health Taskforce 2016 — Rec 37
The Department of Health should continue to support the expansion of programmes that train people to qualify as social workers and contribute to ensuring the workforce is ready to provide high quality social work services in mental health. This should include expanding ‘Think Ahead’ to provide at least an additional …
Health & Social Care
Mental Health Taskforce 2016 — Rec 36
The Department of Health and NHS England should work with the Royal College of GPs and HEE to ensure that by 2020 all GPs, including the 5,000 joining the workforce by 2020/21, receive core mental health training, and to develop a new role of GPs with an extended Scope of …
Health & Social Care
Morecambe Bay Investigation — Rec 8
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify a recruitment and retention strategy aimed at achieving a balanced and sustainable workforce with the requisite skills and experience. This should include, but not be limited to, seeking links with one or more other centre(s) to encourage development of …
Health & Social Care
Wessely Review — Rec 153
The government should consider introducing a minimum waiting time standard for the commencement of an MHA assessment.
Health & Social Care
Accepted
Wessely Review — Rec 83
Patients should have a daily one-to-one session with permanent staff in line with NICE guidelines.
Health & Social Care
Accepted
Darzi Review — Rec 9
Waiting times for hospital procedures have ballooned. The promise is that for most procedures, treatment will start within 18 weeks. In March 2010, there were just over 2.4m on the waiting list, of whom 200,000 had been waiting longer than 18 weeks. Of those, 20,000 had waited more than a …
Health & Social Care
Ockenden Review — Rec 1
Workforce planning and sustainability. Essential action – financing a safe maternity workforce: The recommendations from the Health and Social Care Committee Report: The safety of maternity services in England must be implemented. • The investment announced following our first report was welcomed. However to fund maternity and neonatal services appropriately …
Health & Social Care
Accepted
Acheson Report — Rec 23.1
we recommend the further development of the role and capacity of health visitors to provide social and emotional support to expectant parents, and parents with young children.
Health & Social Care
Tooke MMC Inquiry — Rec 17
Career aspirations and choices should be informed by accurate data on likely employment prospects in all branches of the profession and the likely competition ratios based on historical data, supplemented by professionally agreed foresight projections. Such information should be updated annually by the redesigned medical workforce advisory machinery and made …
Health & Social Care
Tooke MMC Inquiry — Rec 15
Explicit policies should be urgently developed and implemented to manage the transitional ‘bulge’, caused by the integration of eligible doctors into the new scheme, with appropriate credit for prior competency assessed experience.
Health & Social Care
Tooke MMC Inquiry — Rec 14
The content of higher specialty training and the numbers of positions will be informed by dialogue between the Colleges, Deaneries, employers, and medical workforce advisory machinery to allow finer tuning of the nature of the specialist workforce to reflect rapidly evolving technical advances and the locus of care.
Health & Social Care
Tooke MMC Inquiry — Rec 13
The Panel recommends that DH should work with the GMC to create robust databases that hold information on the registered/certificated status of all doctors practising in the UK. This will provide an inventory of the contemporary skill base and number of trained specialists/subspecialists in the workforce, as well as those …
Health & Social Care
Cavendish Review — Rec 18
Statutory guidance should require councils to include payment of travel time as a contract condition for homecare providers.
Health & Social Care
Cavendish Review — Rec 8
HEE and the LETBs should set out a clear implementation plan, with robust measures, to take forward the objective in the HEE mandate to widen participation in recruitment to NHS-funded courses: and develop innovative funding routes for non-traditional staff to progress.
Health & Social Care
Wessely Review — Rec 102
In line with the NHS Workforce Race Equality Standard programme, greater representation of people of black African and Caribbean heritage should be sought in all professions, in particular psychology and occupational therapy.
Health & Social Care
Accepted
Wessely Review — Rec 10
The Government and the CQC should consider ways to resource the likely increase in SOAD reviews, looking at how the model of SOADs can evolve.
Health & Social Care
Accepted
Darzi Review — Rec 11
Care for cardiovascular conditions is going in the wrong direction. Once adjusted for age, the cardiovascular disease mortality rate for people aged under 75 dropped significantly between 2001 and 2010. But improvements have stalled since then and the mortality rate started rising again during the Covid-19 pandemic. Rapid access to …
Health & Social Care
Darzi Review — Rec 10
Cancer care still lags behind other countries. While survival rates at 1-year, 5-years and 10-years have all improved, the rate of improvement slowed substantially during the 2010s. The UK has appreciably higher cancer mortality rates than other countries. No progress whatsoever was made in diagnosing cancer at stage I and …
Health & Social Care
Ockenden Review — Rec 14
Neonatal care. Essential action: There must be clear pathways of care for provision of neonatal care. This review endorses the recommendations from the Neonatal Critical Care Review (December 2019) to expand neonatal critical care, increase neonatal cot numbers, develop the workforce and enhance the experience of families. This work must …
Health & Social Care
Accepted
Tooke MMC Inquiry — Rec 1
The principles underpinning postgraduate medical education and training should be redefined and reasserted, building on those originally articulated in Unfinished Business but in particular emphasising flexibility, ‘broad based beginnings’ and an aspiration to excellence. In devising policy objectives the interdependency of educational, workforce and service policies must be recognised.
Health & Social Care
PHSO casework decisions(3)
P-002469 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs A complained about negligent mental health care for her son, citing failure to diagnose conditions, delayed medication reduction, and prolonged drug prescription.
NHS in England
Feb 2024
P-001917 — South West Yorkshire Partnership NHS Foundation Trust
Mr A complained the Trust delayed referring him to secondary psychological treatment since 2014, leading to extended anxiety, depression, repeated suicidal thoughts, and an attempted suicide.
NHS in England
Not Upheld
Mar 2023
P-002560 — Guy's and St Thomas' NHS Foundation Trust
The Trust poorly managed his chronic pain, only offering pain relief and physiotherapy, and failed to consider alternative treatment options.
NHS in England
Apr 2024
LGO / SPSO decisions(39)
PSOW-202104669 — Betsi Cadwaladr University Health Board
Mrs A complained about the care and management her late husband, Dr A, received at Ysbyty Glan Clwyd (“the Hospital”) in April 2020. She said that medical and nursing staff failed to adequately communicate with her about her husband’s condition. Mrs A said that there were also inadequacies and inconsistencies …
PSOW (Public Services Om…
Health
Upheld
Nov 2022
PSOW-202204110 — Cardiff and Vale University Health Board
Mr X complained about his experience as a transgender man accessing the Health Board’s services. He raised concerns about a specific visit to the A&E Department and more general concerns about how the Health Board ensured that its services were inclusive for LGBTQ patients. Mr X felt that a meeting …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202204912 — Cardiff and Vale University Health Board
Mrs X complained that the Health Board had not provided her with a response to the complaint she submitted to it 10months ago. The Ombudsman decided that there had been a delay in the Health Board’s complaint response, which led Mrs X to contact the Ombudsman. She decided to settle …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202403802 — A GP Practice in the area of Betsi …
Ms X complained that the Surgery had failed to contact her to discuss her ongoing health checks and had not responded to the complaint she made in September 2023. The Ombudsman decided that there had been a failure by the Surgery to respond to the complaint and this had caused …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202404725 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to provide a complaint response to her complaint, which she made to it in November 2023. The Ombudsman found that, whilst the Health Board had been in regular contact with Mrs X, it had failed to issue a complaint response. …
PSOW (Public Services Om…
Health
Oct 2024
201102885 — Lanarkshire NHS Board
Mr A was an elderly man with a history of health problems and restricted mobility. He had been nursed at home for several years. Mr A was admitted to hospital with confusion, infection and back pain. Nine days after admission, he developed pressure ulcers. Mr A remained in the hospital …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2012
201406562 — Grampian NHS Board
Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201403869 — Greater Glasgow and Clyde NHS Board - Acute …
Miss C's father (Mr A) was admitted to Glasgow Royal Infirmary from another hospital where he had been admitted earlier following a fall at home. Mr A was admitted to A&E and then moved to a ward. Mr A died several days after his admission. Miss C was concerned that …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201502825 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C complained about the standard of nursing care provided to her mother (Mrs A) during an admission to Glasgow Royal Infirmary. Ms C felt her mother had been over-sedated with morphine when she was not in pain; was denied food; and that staff had labelled Ms C as being …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2015
201501341 — Fife NHS Board
Miss C complained on behalf of her late mother (Mrs A). Miss C complained that Mrs A's dressings were not changed regularly enough, that the board failed to communicate with her regarding how ill her mother was and, in particular, that Mrs A had signed a do not attempt cardiopulmonary …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2015
201501070 — Tayside NHS Board
Mr C complained that while his wife (Mrs C) was a patient in Murray Royal Hospital, she was assaulted by another patient and suffered a minor injury. The staff told him that Mrs C would be protected from the patient. Mrs C was then assaulted again by the patient and …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2015
201508221 — Grampian NHS Board
Miss C complained about the community nursing care provided to her late mother (Mrs A) who was elderly. Miss C said that the community nurse undertook a procedure which caused Mrs A severe distress and brought her to the point of collapse. Miss C said that she and her mother …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2016
201508844 — Lothian NHS Board
Mr C complained about the medical and dental care and treatment he received from the prison health centre. He suffered from severe pain, particularly head and face pain, due to historic injuries and he raised concerns that adequate pain relief was not provided to him and that nursing staff regularly …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2016
201802151 — Highland NHS Board
Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2018
201800220 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Ms A) at Glasgow Royal Infirmary. Ms A was admitted to the hospital on two occasions due to complications from her gastric …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2019
201908610 — Greater Glasgow and Clyde NHS Board - Acute …
C complained to us about the care and treatment provided to their parent (A). A was admitted to Inverclyde Royal Hospital after they had fallen at home. The following night, A had an unwitnessed fall in the hospital. Around ten days later, A's leg was noted to be at an …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2021
201906846 — Forth Valley NHS Board
C complained about the nursing care that they received whilst an in-patient at Forth Valley Royal Hospital. C complained that during their stay in the hospital there were errors in the administration of their medication and that they were manhandled by a member of staff when trying to get out …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2021
202002913 — Fife NHS Board
C complained about the care and treatment their parent (A) received from district nurses in relation to the management of sores/ulcers on their legs while resident at a care home. In particular, C complained that district nursing staff had failed to adequately monitor and treat A's sores/ulcers to such an …
SPSO (Scottish Public Se…
Health
Upheld
May 2022
202101294 — Fife NHS Board
C complained about the care and treatment provided to their late parent (A) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2023
202106438 — Glasgow City Health and Social Care Partnership
C complained about the care and treatment provided to their parent (A) who had dementia. C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact …
SPSO (Scottish Public Se…
Health and Social Care
Partly Upheld
Sep 2023
202306916 — Tayside NHS Board
C complained about the nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided. We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2024
202306836 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate. C complained …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2024
202209316 — Fife NHS Board
C complained about the care and treatment that their sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2025
202404349 — Highland NHS Board
C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025
202402836 — Borders NHS Board
C complained about the lack of care and understanding for their parent (A) who died in hospital. C referred to incorrect information being passed to the family and the lack of notes and records of events which occurred during A's admission. C said that while the board replied with some …
SPSO (Scottish Public Se…
Health
Aug 2025
202309879 — Forth Valley NHS Board
C’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025
202305480 — Fife NHS Board
C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2025
23-014-851 — Gloucestershire County Council
Summary: The Council failed to complete an Education, Health and Care (EHC) needs assessment within statutory timescales. This delay was, in part, due to a shortage of Educational Psychologists. The Council will make a symbolic payment to Mrs Y and D. The Council will also outline the service improvements it …
LGO (Local Government & …
Education
Upheld
Apr 2024
23-012-356 — Norfolk County Council
Summary: There was fault in how the Council dealt with assessment and care planning for Mr K who is disabled, as well as assessment and support for his mother Ms B. There was fault in how the Council dealt with direct payments, and with recruitment of personal assistants. It has …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
201508595 — Lothian NHS Board
Mr C complained about the care and treatment provided to his wife (Mrs A) when she was admitted to the Western General Hospital for radiotherapy to treat a spinal condition. Mr C said that nursing staff failed to provide reasonable care in relation to the taking of blood samples, pressure …
SPSO (Scottish Public Se…
Health
Not Upheld
Jan 2017
201508664 — Forth Valley NHS Board
Ms C had an operation on a toe of her left foot at Forth Valley Royal Hospital. Ms C's foot was put in a plaster cast and when she returned the following month for it to be changed, a member of staff tried to realign the toe contrary to the …
SPSO (Scottish Public Se…
Health
Feb 2017
201800508 — Highland NHS Board
Mrs C complained about the nursing care that her late mother (Mrs A) received at Broadford Hospital. Mrs C had a number of concerns about the board's record-keeping and also complained about the communication from the nursing staff. Mrs A was admitted to the hospital where a provisional diagnosis of …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2019
201805658 — Highland NHS Board
Miss C complained on behalf of her brother (Mr A) about the care and treatment he received while he was a day patient at a psychiatric hospital. Miss C complained that the hospital wrongly decided to not detain Mr A under the Mental Health (Care and Treatment) Act (Scotland) 2003 …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2019
PSOW-202307593 — Aneurin Bevan University Health Board
Mrs S complained that Aneurin Bevan University Health Board had failed to respond to her complaint, submitted in August 2022. The Ombudsman found that the Health Board had provided a full response to concerns raised by Mrs S in December 2022, but had failed to address the earlier concerns that …
PSOW (Public Services Om…
Health
Feb 2024
20-014-052b — Northern Care Alliance NHS Foundation Trust (20 014 …
Summary: Mr B and Mr C complain about the care their late mother Mrs D received from a Council-funded care home, from district nurses and from a mental health outreach team. They also complain the Council delayed re-assessing her needs. We found the Home failed to properly manage Mrs D’s …
LGO (Local Government & …
Health
Not Upheld
Feb 2022
23-018-187 — Cheshire West & Chester Council
Summary: Miss X complained the Council delayed in carrying out her son’s social care assessment. The Council has now agreed to carry it out within one month. We will not investigate because further investigation is unlikely to achieve anything more. We will not investigate Miss X’s other complaint that the …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
201101678 — Greater Glasgow and Clyde NHS Board
Mrs C had fertility treatment which began in 2008. She had a successful pregnancy in 2009 and in 2011 was invited back for further treatment. On attending the appointment, she was advised there had been an administrative error, and she should not have been invited for further treatment as she …
SPSO (Scottish Public Se…
Health
Upheld
May 2012
25-005-913c — Leicestershire Partnership NHS Trust (25 005 913c)
Summary: We will not investigate Miss X’s complaint about her mother’s care and treatment during September and October 2022. This is because a significant amount of time has passed since the events Miss X is complaining about occurred and it would have been reasonable for Miss X to complain to …
LGO (Local Government & …
Health
Dec 2025
25-005-913b — University Hospitals of Leicester NHS Trust (25 005 …
Summary: We will not investigate Miss X’s complaint about her mother’s care and treatment during September and October 2022. This is because a significant amount of time has passed since the events Miss X is complaining about occurred and it would have been reasonable for Miss X to complain to …
LGO (Local Government & …
Health
Dec 2025
Domestic Homicide Reviews(16)
West Berkshire — recommendation 2
A review of the number of staff employed within the Safeguarding department to establish if there are sufficient numbers to effectively manage current work-load from across the SCAS region.
South Central Ambulance Service NHS Foundation …
South Central Ambulance Service …
Hammersmith and Fulham — recommendation WLT9
Medical vacancies within the service should be filled and appropriate mechanisms in place with the Medical HR department of the Trust to ensure that recruitment strategies are in place to reduce vacancies. The Training Programme Director should also be sighted on trainee gaps.
West London NHS Trust
West London NHS Trust
Wiltshire — recommendation 8.4.3 ii)
Review the staffing of the PCLS service to ensure that there are adequate numbers of substantive clinical and administrative staff
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
West Berkshire — recommendation 6
Staff welfare should receive a greater priority from senior management and a renewed focus on staff retention and health should be increased in areas with repeated high turnover with risks of staff burnout.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
West Berkshire — recommendation 3
Activity levels for both of the services should be set in line with capacity, and a staff skill mix set that is appropriate against the acuity and activity presented.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
West Berkshire — recommendation 1
We recommend that local mental health crisis services be strengthened, not only in terms of capacity to ensure swift response, but that they maintain evidence based methods for interview, assessment and response to mental health crisis. The matter of investment in these services will rest with local commissioners, but it …
Local mental health crisis services | …
Bradford — recommendation Bradford Teaching Ho
Staff member in a permanent post in order that routine enquiry can be successfully embedded into BTHFT in Accident and Emergency, maternity services and other high usage areas where women are present.
Bradford Teaching Hospitals NHS Foundation Trust
Bradford Teaching Hospitals NHS …
Hammersmith and Fulham — recommendation WLT6
The service ensures patients requiring care coordination are appropriately allocated as soon as is practicably possible. Capacity issues should be escalated to relevant commissioners.
West London NHS Trust
West London NHS Trust
Leicester — recommendation 6
It is recommended that caseloads of the multi-professional Community Mental Health Teams be assessed for acuity and limits set to ensure that the clinicians have the capacity to deliver the services to the required standards. This should be achieved within three months, and monitoring systems put in place to enable …
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Cornwall — recommendation 8
We recommend that a process and protocol be put in place to guide practitioners and managers about how best to ensure continuity of care provisions, most notably, continuity of worker. Recognising the constraints of workforce capacity and workload, it is nevertheless important to place emphasis on the need to provide …
NHS Kernow | Cornwall Foundation Partnership …
NHS Kernow
Wolverhampton — recommendation 2
Wolverhampton CSP to highlight the need for sufficient IDVA capacity to be provided by city-wide commissioners in line with CAADA recommendations that IDVA teams should have specialisms across the team in the criminal justice system, family courts, substance use, mental health, young people, safeguarding, sexual violence, housing, and BME and …
Wolverhampton Community Safety Partnership
Wolverhampton — recommendation 1
That an independent review of the Wolverhampton MARAC is undertaken after systemic, organisational and staffing issues have been addressed, to ensure compliance with best practice.
Safer Wolverhampton Partnership
Cornwall — recommendation 8
We recommend that a process and protocol be put in place to guide practitioners and managers about how best to ensure continuity of care provisions, most notably, continuity of worker. Recognising the constraints of workforce capacity and workload, it is nevertheless important to place emphasis on the need to provide …
NHS Kernow | Cornwall Partnership NHS …
NHS Kernow
Tower Hamlets — source paragraph 156
The internal learning from the Healthcare Trust IMR questions whether delays in the OH service appear to have been related to the limited resources available to manage cases promptly. The Trust commissioned a strategic review of OH services which has recently been completed (November 2017). The Trust needs to consider …
London Healthcare NHS Trust
Leicester — recommendation 6
Explore the possibility of securing additional funding to recruit a permanent IDVA to work across UHL, alongside the UHL safeguarding teams
University Hospitals of Leicester NHS Trust
University Hospitals of Leicester …
Enfield — recommendation 8
Financial resources for funding increased bed capacity within the mental health sphere is required to meet demonstrated demand. Additional resources will also be required to adequately fund co-ordination between partner agencies within and beyond the NHS in order to implement the “Right Care, Right Person” policy.
Department of Health and Social Care
Department of Health and …
CQC enforcement actions(24)
Warning Notice: West London NHS Trust
CQC told West London NHS Trust to make improvements to its community-based mental health services following an inspection in May. The inspection found significant staffing issues and delays to people accessing treatment, which put some people at risk of harm. …
Jul 2022
Warning Notice: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission (CQC) served University Hospitals Birmingham NHS Foundation Trust with a warning notice following inspections carried out in December. CQC found that the trust needed to make significant and immediate improvements to its staffing levels in medical …
Good Hope Hospital
Apr 2023
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an inspection of their community-based mental health services for people of working age in October. Inspectors found safety concerns still needed addressing …
Mar 2023
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) took enforcement action, serving Greater Manchester Mental Health NHS Foundation Trust with two Section 29A warning notices. One notice related to ligature and fire risks, and the other to staffing and governance, requiring significant improvements …
Nov 2022
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Greater Manchester Mental Health NHS Foundation Trust. This action followed a focused inspection in April of community-based mental health services for adults of working age. Inspectors found that patients and …
Jun 2022
Warning Notice: Leeds and York Partnership NHS Foundation Trust
The Care Quality Commission (CQC) re-rated the long stay or rehabilitation mental health wards for working age adults, run by Leeds and York Partnership NHS Foundation Trust, as requires improvement. Following an inspection on 10 and 11 March, CQC found …
Asket Croft, Asket House and Newsam Centre Ward
Jul 2026
Conditions Imposed: Mid and South Essex NHS Foundation Trust
The Care Quality Commission (CQC) placed conditions on Basildon University Hospital’s registration following inspections of its medical care and urgent and emergency services between December 2024 and March 2025. CQC found serious overcrowding in the emergency department, risking people’s safety, …
Basildon University Hospital
Oct 2025
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission issued three formal warnings to Medway NHS Foundation Trust following an unannounced inspection of its maternity and midwifery services at Medway Maritime Hospital in August. The inspection found that the trust did not meet national regulations …
Medway Maritime Hospital
Oct 2013
Warning Notice: Buckinghamshire Healthcare NHS Trust
CQC issued a formal warning to Buckinghamshire Healthcare NHS Trust following an unannounced visit to Amersham Hospital on 4 July 2013. Inspectors found that the service was not taking appropriate steps to ensure sufficient numbers of suitably qualified staff were …
Sep 2013
Warning Notice: Northern Devon Healthcare NHS Trust
The Care Quality Commission (CQC) inspected medical care services at North Devon District Hospital in July following concerns about staffing levels. Inspectors found a high number of vacancies and issues with medical staff availability and responsiveness for deteriorating patients, which …
North Devon District Hospital
Nov 2021
Warning Notice: Mid and South Essex NHS Foundation Trust
CQC issued a warning notice requiring Mid and South Essex NHS Foundation Trust to make urgent improvements to ensure mothers and babies are safe in its maternity services at Basildon University Hospital. Inspectors found several concerns, including high-risk women giving …
Basildon University Hospital
Aug 2020
Urgent Enforcement Action: Mid and South Essex NHS Foundation Trust
The Care Quality Commission issued an urgent notice of decision under Section 31 of the Health and Social Care Act 2008, placing conditions on Mid and South Essex NHS Foundation Trust's registration. This action followed an inspection of maternity services …
Basildon University Hospital
Nov 2020
Warning Notice: West London Mental Health NHS Trust
The Care Quality Commission issued a Warning Notice to West London Mental Health NHS Trust, requiring significant improvements in the care of patients at Broadmoor Hospital. Inspectors found the trust did not have enough suitably qualified staff to meet patient …
Broadmoor Hospital in Berkshire
Dec 2016
Warning Notice: Royal Cornwall Hospitals NHS Trust
The Care Quality Commission issued a Warning Notice to Royal Cornwall Hospitals NHS Trust. This notice requires the trust to make significant improvements in the care of patients at the Royal Cornwall Hospital. Inspectors found issues including insufficient staffing, increasing …
Royal Cornwall Hospital
Sep 2017
Warning Notice: Worcestershire Acute Hospitals NHS Trust
Following an inspection in November and December 2016, the Care Quality Commission issued a warning notice to Worcestershire Acute Hospitals NHS Trust. This action was taken because significant improvements were required in relation to staffing levels, governance, investigation of clinical …
Jun 2017
Warning Notice: Devon Partnership NHS Trust
The Care Quality Commission (CQC) told Devon Partnership NHS Trust that it must make urgent improvements to the quality of its medium forensic inpatient or secure wards. Following an urgent inspection in August 2020, CQC found concerns relating to patient …
Dewnans Centre at Langdon Hospital in Dawlish
Oct 2020
Warning Notice: Bedford Hospital NHS Trust
The Care Quality Commission (CQC) issued formal warnings to Bedford Hospital NHS Trust following unannounced inspections in July 2013. CQC found the trust was not meeting national standards of quality and safety, specifically regarding staffing levels and the care and …
Bedford
Aug 2013
Warning Notice: East Sussex Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to East Sussex Hospitals NHS Trust, requiring urgent improvements to patient care. Inspectors found insufficient staff to support proper patient care in some areas, and that care plans and risk assessments …
Jun 2011
Warning Notice: Plymouth Hospitals NHS Trust
The Care Quality Commission issued a formal warning to Plymouth Hospitals NHS Trust, requiring urgent improvements to protect patients undergoing surgery at Derriford Hospital. This action followed an unannounced inspection where the trust did not meet five national standards, including …
Derriford Hospital
Jul 2013
Warning Notice: Barts Health NHS Trust
The Care Quality Commission told Barts Health NHS Trust that it must improve patient care and support given to staff at the Royal London Hospital. This followed an unannounced inspection in June where the hospital was found to be not …
Royal London Hospital
Sep 2013
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, requiring significant improvements to its community-based mental health services for adults of working age. This followed an inspection where CQC found that …
May 2018
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) told Barts Health NHS Trust that improvements are needed in the diagnostic imaging departments at The Royal London Hospital and Whipps Cross University Hospital. Following a focused inspection in May, CQC found serious concerns including …
The Royal London Hospital and Whipps Cross Univer…
Jul 2021
Warning Notice: Lincolnshire Partnership NHS Foundation Trust
The Care Quality Commission told Lincolnshire Partnership NHS Foundation Trust that it must take action to improve the care of those accessing its specialist mental health and learning disability services. Reports identified areas for improvement including the safety and suitability …
Mar 2011
Warning Notice: North Middlesex University Hospital NHS Trust
Following an unannounced inspection in April, CQC inspectors issued a Warning Notice to North Middlesex University Hospital NHS Trust. This required the trust to significantly improve the treatment of patients attending the emergency department. Inspectors found significant delays in patient …
Jul 2016