Complaint record keeping failures
Failures in maintaining accurate and procedural records for managing complaints in residential care homes.
Source spread
Where this theme appears
This theme appears across 25 independent accountability sources, so the source mix matters as much as the headline total.
102 inquiry recs
65 PFD reports
248 committee recs
6 HSSIB recs
166 CQC actions
3 HMICFRS recs
18 ICIBI recs
33 PPO recs
27 IOPC recs
16 NAO recs
8 VC recs
502 IMB recs
7 IMB reports
2 Scottish FAIs
13 Article 2 learning points
13 detention investigation recs
267 DHR recs
631 PHSO decisions
8842 LGO/SPSO decisions
9 CJINI reports
1 CQC enforcement action
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(102)— showing 50 strongest matches
125 — Label drawings made in interviews
Recommendation: Any drawings made during an interview should be labelled at the time of creation to enable the occasion and their creator to be clearly identified (17.67).
Unknown
124 — Full written record after each interview
Recommendation: Whether or not there is mechanical recording, a full written record must be made as soon as possible after each interview (17.66).
Unknown
123 — Improve and monitor recording
Recommendation: Every effort should be made to improve recording techniques and maintain consistent recordings throughout a series of interviews (17.64) The standards and practices of recording should be regularly monitored (17.65).
Unknown
118 — Value contribution of foster carers
Recommendation: Where investigative interviews are being undertaken the contribution of foster carers must be valued, collected and recorded (17.58).
Unknown
43 — Record decision when Order cannot be executed
Recommendation: Where it is considered that a Child Protection Order should be executed but the Order cannot be effected immediately a clear written record should be made of the decision to obtain it, the reason for it and the reason why …
Unknown
42 — Record grounds for seeking an Order
Recommendation: A record should be kept of the grounds for any decision to seek a Child Protection Order (16.14).
Unknown
43 — Church in Wales record-keeping policies
Recommendation: The Church in Wales should introduce record-keeping policies relating to safeguarding, complaints and whistleblowing. These should be implemented consistently across dioceses. The Church should develop policies and training on the information that must be recorded in files. The Church should …
No response yet
AFA-1 — Patient focus and complaints
Recommendation: The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication …
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
R40 — Record all complaints in electronic system
Recommendation: In HSCTs all complaints, regardless of whether they are resolved immediately at ward level, should be recorded in the Trust’s electronic complaints management system. In private and third sector facilities the Registered Home Manager should be informed of all concerns …
No response yet
F133 — Role of commissioners in complaints
Recommendation: Commissioners should be entitled to intervene in the management of an individual complaint on behalf of the patient where it appears to them it is not being dealt with satisfactorily, while respecting the principle that it is the provider who …
Gov response: Accepted in principle. While we accept the spirit of this recommendation, we are concerned that it risks creating uncertainty over roles and responsibilities in the management of complaints. Clarity and consistency are critical for the …
Accepted in part
F121 — Learning and information from complaints
Recommendation: The Care Quality Commission should have a means of ready access to information about the most serious complaints. Their local inspectors should be charged with informing themselves of such complaints and the detail underlying them.
Gov response: Accepted. Information received from people who use care services about the quality and safety of their care, including concerns and complaints, is a vital source of information which needs to be available to the regulator. …
Accepted
F120 — Learning and information from complaints
Recommendation: Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board …
Gov response: Accepted in part. We accept that commissioning bodies play an important role in ensuring that the organisations from which it commissions services are delivering effective and open complaints arrangements, and delivering their statutory responsibilities. Complaints …
Accepted in part
F119 — Learning and information from complaints
Recommendation: Overview and scrutiny committees and Local Healthwatch should have access to detailed information about complaints, although respect needs to be paid in this instance to the requirement of patient confidentiality.
Gov response: Accepted. Complaints data, along with other sources of feedback, have the potential to provide important information to local Healthwatch Organisations and Overview and Scrutiny Committees. It is important that Trusts respect patient confidentiality when releasing …
Accepted
F118 — Learning and information from complaints
Recommendation: Subject to anonymisation, a summary of each upheld complaint relating to patient care, in terms agreed with the complainant, and the trust's response should be published on its website. In any case where the complainant or, if different, the patient, …
Gov response: Accepted in part. An open culture demands that information is available to service users, their families and carers to enable them to make informed choices about their healthcare. Trusts currently have to publish an annual …
Accepted in part
F115 — Investigations
Recommendation: Arms-length independent investigation of a complaint should be initiated by the provider trust where any one of the following apply: A complaint amounts to an allegation of a serious untoward incident; Subject matter involving clinically related issues is not capable …
Gov response: Accepted in part. Investigation of any complaints should be proportionate to the needs of the individual case. This follows the fundamental principle that complaints cases should be handled according to the needs of that individual …
Accepted in part
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Gov response: Accepted. A fundamental principle of the current complaints arrangements for handling NHS and adult social care complaints is that a case should be handled according to the needs of that individual case. Investigation should be …
Accepted
F113 — Complaints handling
Recommendation: The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.
Gov response: Accepted. At present, standards of complaints handling are judged on the basis of the 2009 regulations and the Health Service Ombudsman’s Principles of Good Complaints Handling. While both of these remain important, a more formal …
Accepted
L14 — Free Complaints Process
Recommendation: It should continue to be the case that complainants are able to bring complaints free of charge.
Gov response: In volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key “requirements” that an independent self-regulatory body should meet, including independence of appointments …
Accepted in part
L13 — Complaints Committee Composition
Recommendation: Serving editors should not be members of any Committee advising the Board on complaints and any such Committee should have a composition broadly reflecting that of the main Board, with a majority of people who are independent of the press.
Gov response: In volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key “requirements” that an independent self-regulatory body should meet, including independence of appointments …
Accepted in part
L12 — Complaint Decision Responsibility
Recommendation: Decisions on complaints should be the ultimate responsibility of the Board, advised by complaints handling officials to whom appropriate delegations may be made.
Gov response: In volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key “requirements” that an independent self-regulatory body should meet, including independence of appointments …
Accepted in part
L11 — Power to Hear Complaints
Recommendation: The Board should have the power to hear and decide on complaints about breach of the standards code by those who subscribe. The Board should have the power (but not necessarily in all cases depending on the circumstances the duty) …
Gov response: In volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key “requirements” that an independent self-regulatory body should meet, including independence of appointments …
Accepted in part
L10 — Complaint Handling Mechanism
Recommendation: The Board should require all those who subscribe to have an adequate and speedy complaint handling mechanism; it should encourage those who wish to complain to do so through that mechanism and should not receive complaints directly unless or until …
Gov response: In volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key “requirements” that an independent self-regulatory body should meet, including independence of appointments …
Accepted in part
13 — Improve complaints handling
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses …
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
113 — Training in interviewing and recording
Recommendation: The importance of full training in the art of interviewing and the techniques of recording should be fully recognised (17.52).
Unknown
5 — Reform Church of England clergy discipline for safeguarding
Recommendation: The Church of England should make changes and improvements to the way in which it responds to safeguarding complaints (whether related to allegations of abuse, or a failure to comply with or respond to the Church's safeguarding policies and procedures) …
No response yet
R42 — Regular updates on complaint progress
Recommendation: Complainants must be regularly updated and informed of the progress of any investigation, including when the process concludes without a specific finding.
No response yet
R41 — Inform complainants of complaint management process
Recommendation: Complainants should immediately be informed of how their complaint will be managed (locally or through the corporate complaints process) along with a clear explanation of the corresponding level of investigation and oversight this entails.
No response yet
WATE-(18) — Appoint senior officer to strategise serious staff misbehaviour complaints
Recommendation: When a complaint alleges serious misbehaviour by a member of staff, the Director of Social Services should appoint a senior officer to formulate an overall strategy for dealing with the complaint, including such matters as liaison with the police in …
Unknown
WATE-(4) — Define specific duties for Children's Complaints Officers, prioritising child's best interests
Recommendation: Amongst the duties of the Children's Complaints Officer should be: (a) to act in the best interests of the child; (b) on receiving a complaint, to see the affected child and the complainant, if it is not the affected child; …
Unknown
WATE-(3) — Require appointment of independent Children's Complaints Officer in every social services authority
Recommendation: Every social services authority should be required to appoint an appropriately qualified or experienced Children's Complaints Officer, who should not be the line manager of residential or other staff who may be the subject of children's complaints or complaints relating …
Unknown
BRIS-36 — Establish independent, swift, and thorough complaints handling with advocacy for patients
Recommendation: Complaints should be dealt with swiftly and thoroughly, keeping the patient (and carer) informed. There should be a strong independent element, not part of the trust’s management or board, in any body considering serious complaints which require formal investigation. An …
Unknown
R33 — Nursing complaint investigation
Recommendation: Health Boards should ensure that where a complaint is made about nursing practice on a ward this complaint is investigated by an independent senior member of Nursing Management.
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
6a — Communicating complaint escalation
Recommendation: We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and independent sector.
Gov response: Accept The PHSO is currently piloting the NHS Complaint Standards, which set out in one place the ways in which the NHS should handle complaints, including the need for organisations to ensure people know how …
Accepted
F259 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre, in consultation with the Department of Health, the NHS Commissioning Board and the Parliamentary and Health Service Ombudsman, should develop a means of publishing more detailed breakdowns of clinically related complaints.
Gov response: Accepted. The Department of Health will work with the Health and Social Care Information Centre to put complaints data into the existing NHS electronic data collection system, better enabling comparison between hospitals.
Accepted
F134 — Role of commissioners in provision of support for complainants
Recommendation: Consideration should be given to whether commissioners should be given responsibility for commissioning patients' advocates and support services for complaints against providers.
Gov response: Accepted. The Health and Social Care Act 2012 gave responsibility for commissioning NHS complaints advocacy to individual Local Authorities; the Local Authorities took responsibility from April 2013. Local Authorities are best able to determine the …
Accepted
F117 — Support for complainants
Recommendation: A facility should be available to Independent Complaints Advocacy Services advocates and their clients for access to expert advice in complicated cases.
Gov response: Accepted in part. We agree that expert advice should be provided in appropriate cases, and in appropriate cases, the providers of NHS complaints advocacy would obtain advice from an independent clinical expert. However complaints advocacy …
Accepted in part
F116 — Support for complainants
Recommendation: Where meetings are held between complainants and trust representatives or investigators as part of the complaints process, advocates and advice should be readily available to all complainants who want those forms of support.
Gov response: Accepted. People making complaints can feel isolated and intimidated when in meetings with complaints managers and trust representatives. Some patients, relatives or friends remain deeply affected by their experiences. It is right that support is …
Accepted
F109 — Effective complaints handling
Recommendation: Methods of registering a comment or complaint must be readily accessible and easily understood. Multiple gateways need to be provided to patients, both during their treatment and after its conclusion, although all such methods should trigger a uniform process, generally …
Gov response: Accepted. Feedback of any kind, but particularly concerns and complaints, are important; they enable things to be put right for the complainant and drive the improvement of hospital services. But there is evidence that not …
Accepted
L20 — Compliance Record Keeping
Recommendation: The Board should have both the power and a duty to ensure that all breaches of the standards code that it considers are recorded as such and that proper data is kept that records the extent to which complaints have …
Gov response: In volume IV of the report, Lord Justice Leveson sets out proposals for independent self-regulation organised by the media. He details the key “requirements” that an independent self-regulatory body should meet, including independence of appointments …
Accepted in part
34 — CQC and PHSO memorandum of understanding
Recommendation: The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service …
Gov response: 90. We accept this recommendation. The Investigation found that the lack of co- ordination between the Care Quality Commission and the Parliamentary and Health Service Ombudsman was a contributory factor to the ongoing inability of …
Accepted
31 — Fundamental review of NHS complaints system
Recommendation: The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature …
Gov response: 72. We accept this recommendation in principle and recognise that there are still challenges to overcome if we are to see improvements in the way complaints are handled in the NHS. However, we do not …
Accepted in part
RHI-28 — Record Keeping Culture and Audit
Recommendation: The culture and practice of record keeping and access to records within the Northern Ireland Civil Service needs to change so that staff responsible for a given area of work have easy access to the analysis and decisions underpinning the …
Gov response: These recommendations can be accepted in full. They have been addressed through work to date through: • revisions to the NICS Code of Ethics and production of the Guidance for Ministers; • new corporate guidance …
Accepted
BAHA-17 — CPERS Complaints Procedure
Recommendation: JDP 1-10 should incorporate the requirement that on entry to and exit from a theatre level detention facility, CPERS are proactively asked whether or not they have any complaints concerning their treatment. This should not be done in the presence …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
36 — Information booklet for patients
Recommendation: There should be a simple and attractive information booklet which should be given to each patient and his relatives on arrival specifying, among other things, the procedure for making suggestions and complaints.
Unknown
2 — Procedures for complaints from staff and patients
Recommendation: There is a need for improvement in procedures to deal with complaints from staff and patients: we refrain from making a more specific recommendation because, since our Inquiry began, a special Committee has been set up to look into complaints …
Unknown
78 — Record and share discussions
Recommendation: Noting discussions between relatives, clinicians and pathologists and providing a copy to each party involved.
Unknown
14 — Recording cell-share requests
Recommendation: The guidelines should contain guidance on how such requests should be recorded, but there is no need for such requests to be treated as formal applications under the requests and complaints procedures.
Unknown
FP26 — Recommendation 26
Recommendation: Characteristics first found at the comparison stage should be included in any note of the examination. Less weight should be attached to such characteristics.
No response yet
FP23 — Recommendation 23
Recommendation: At the analysis stage an examiner should assess the quality of the mark. If the examiner considers it to be complex this should be recorded and the separate process for complex marks recommended in recommendation 42 should be followed.
No response yet
FP15 — Recommendation 15
Recommendation: Where third level detail is relied upon in making a comparison this should be included in any note of the examination.
No response yet
Prevention of Future Deaths reports(65)— showing 50 strongest matches
Kate Louise Pierce
Concerns: The coroner raised concerns regarding a doctor's fitness to practice, following a misdiagnosis and alleged misleading of parents about a second opinion, noting the doctor remains in practice.
Response (GMC): • The GMC stated it conceded a Judicial Review, which resulted in the closure of its investigation into past events due to statutory rules regarding events over five years old. … (AI summary)
Responded
Jonathan Thorpe
Concerns: During GP consultations for a patient with depression and a history of self-harm, the coroner noted no reference to Mental Health Services, nor was advice sought regarding previous involvement or need for further input.
Overdue
Pauline Meredith
Concerns: The coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Response (Browning Street Surgery): • The practice has formally instigated a programme of regular meetings to review all deaths in patients under 50 and will develop criteria to identify complex patients for discussion at … (AI summary)
Overdue
Clive Clinton
Concerns: The coroner noted apparent failings in the care home's complaints procedure, which allowed staff to withhold concerns from senior management. There was also a lack of information for families on how to direct complaints to a more senior level within the organisation.
Overdue
Marion Turner
Concerns: A message from Ms Turner's solicitor about her mental health concerns was left for her CPN but remained unread until the next day, indicating a delay in processing important patient information.
Overdue
Stanley Bere
Concerns: The Cardex system was not properly completed, with missing information on falls and family concerns. Incident reports were not followed up or updated, and a lack of cross-referencing contributed to delayed identification of injuries.
Overdue
Thomas Dixon
Concerns: The coroner noted failures in scheduling follow-up and urgent appointments, alongside missing documentation. Concerns were raised regarding the absence of systems to identify and correct these issues, and the timeliness of implementing an action plan.
Overdue
Seweryn Glowinski
Concerns: The coroner identified a lack of communication between prison units regarding a prisoner's transfer plan and risk assessment. Documentation for detention contained errors due to copying, and senior managers were unaware of rules for transferring ACCT prisoners to segregation.
Overdue
Connor Smith
Concerns: Concerns were raised about the quality of the PPO's investigation, specifically regarding inaccurate attendance records at a segregation review hearing. Such errors could impede the learning of lessons from similar cases.
Response (Prisons Probation Ombudsman): • The Prisons and Probation Ombudsman (PPO) acknowledged an apparent minor factual inaccuracy in its report. • The PPO stated that it did not believe further specific action could be … (AI summary)
Response (HM Prison and Probation Service): • A notice was issued to senior managers who chair Segregation Review Boards. • The notice advised that documentation for meetings must not have names entered in advance and that … (AI summary)
Overdue
Samia Shara
Concerns: The coroner identified that long, complex 999 and 111 calls were not available for audit by the CCG to improve outcomes. Concerns were also raised about call takers being able to downgrade calls to a lower acuity pathway.
Overdue
Philip Smith
Concerns: Inadequate and incomplete nursing and medical records were identified regarding patient observations, medication administration, and an incident. A junior doctor declined a senior medical review despite a senior nurse's concerns about patient deterioration.
Overdue
Kimberley Lindfield
Concerns: The coroner raises concerns about the lack of an auditing process for the new mental health referral system, as well as the absence of clear written policies for increased patient observations and for clinical reviews responding to new risks. The report also notes the importance of reminding staff about record-keeping responsibilities and conducting periodic audits.
Response (Manchester Mental Health NHS): • The Trust stated that induction training for junior medical staff incorporates advice on assessing patients regardless of medical fitness. • Revised Urgent Care Standard Operating Procedures are being finalised … (AI summary)
Response (Department of Health): • The Department of Health reviewed and revised the Mental Health Act 1983 Code of Practice, which came into effect on 1st April 2015 and includes advice on enhanced observation. … (AI summary)
Responded
John Dack
Concerns: Mr Dack missed follow-up appointments due to an incorrect address in his medical notes, despite staff being notified twice. The coroner identified this as a recurring administrative issue needing a review of the hospital's system for managing patient addresses.
Response (Barts Health NHS Trust): • The ward matron was asked to remind staff about the importance of accurately changing patient details. • The importance of accurately changing patient details is emphasized to relevant staff. (AI summary)
Responded
Tom Sawyer and Danny Winters
Concerns: The coroner identified inadequate radio logging practices, including reliance on handwritten logs and missing FIRESNET logs. Concerns were also raised about the lack of secure digital recording capability for encrypted radio signals.
Response (Ministry of Defence): • The Ministry of Defence stated that the next generation of tactical command, control and communications system for Defence includes a requirement for an automated secure voice log. • The … (AI summary)
Responded
Joyce Hartford
Concerns: The coroner noted incomplete and inaccurate nursing tools, assessments, records, and discharge summaries. Despite audits by the Trust to improve record keeping, no material improvement in standards was observed.
Response (Pennine Acute Hositals NHS Trust): • Ward T7 undertakes monthly and weekly audits of nursing documentation quality, providing feedback to staff. • Trust-wide Nursing Metrics have been introduced, including audits of documentation quality, and a … (AI summary)
Responded
William Tolen
Concerns: The coroner identified inadequate and fragmented record-keeping at the care home, impacting staff's ability to track care and confirm facts. Concerns included insufficient staff training for medical situations, delays in podiatry care, and the absence of a post-incident review.
Response (William Tolen): • Staff received further supervision and training in relation to documentation, and instructions were added regarding specific concerns. • Visiting professionals were advised that the home would not accept the … (AI summary)
Responded
Edna Cleaton
Concerns: The practice lacked systems to ensure patients on citalopram received appropriate medical reviews every 3-6 months, as one patient went over 3 years without review, potentially missing signs of deterioration.
Response (Edna Cleaton): • The practice stated that repeat prescriptions for antidepressants are issued for a maximum of six months, requiring a review thereafter. • The practice confirmed the existence of a repeat … (AI summary)
Responded
Margaret Pegnall
Concerns: The coroner noted the GP's domestic violence flowchart was vague and focused on depression rather than abuse risk, lacking a specific questionnaire for domestic abuse. There was also no method for staff to escalate urgent patient calls.
Response (Margaret Pegnall): • The practice incorporated a DASH-based questionnaire and assessment for domestic abuse into its protocol. • DASH questionnaire responses are now scanned to patient records to document domestic abuse and … (AI summary)
Responded
Matthew Roberts
Concerns: The coroner identified an absence of policies for logging and scrutinising faxed referrals, and for the EI team to read all information before initial risk assessment. This meant patient needs were not fully understood, and an organizational review of the death was delayed.
Response (Sussex Partnership NHS Trust): • The Trust designed and displayed posters to guide staff on managing faxes and requested 100% compliance with Information Governance Training. • New shared standards and guidelines for accepting referrals … (AI summary)
Responded
Marian Dale
Concerns: Concerns were raised regarding the District Nursing Team's record-keeping system, where patient notes were held solely at the patient's address with no central contemporaneous record, leading to difficulties in evidence provision and post-death retrieval.
Overdue
Grant Richards
Concerns: The coroner noted the GP surgery's failure to action a recommended chest clinic follow-up from an A&E discharge summary, alongside a lack of contingency systems and poor attention to documents, including faxes from mental health agencies.
Overdue
Thomas Whitfield
Concerns: The coroner noted a lack of documented records regarding family concerns about suicide risk communicated to hospital staff, particularly concerning telephone conversations. There were also no current systems for monitoring or recording such calls to verify their content.
Overdue
David Evans
Concerns: The coroner noted that the doctor performing a FAST ultrasound was not properly trained or supervised, and that records of these examinations are not routinely stored. The report further identifies a need for appropriate care escalation when a symptomatic Abdominal Aortic Aneurysm is identified in the emergency department.
Overdue
Janet Williams
Concerns: Inadequate recording of Ms Williams' care plan led to missed reviews and delayed medical appointments. Additionally, the care coordinator did not address family concerns and made undeclared retrospective entries in medical records.
Overdue
Sean Plumstead
Concerns: Winchester Prison has inadequate systems for storing and retrieving telephone recordings and staff interview recordings, often providing only summary transcripts. This lack of proper retention of important electronic and documentary evidence with specific prisoner records is a recurring issue, posing a risk for future deaths.
Response (HM Prison Probation Services): • HMP Winchester has assigned temporary staff to transcribe encrypted telephone call recordings and implemented a new protocol for information and evidence gathering. • Recordings of staff interviews have been … (AI summary)
Response (Carillion): • Carillion familiarised itself with PSI64/2011 and its updates to ensure compliance with HMPPS policies. • Carillion contacted HMPPS to support Prison Governors in ensuring staff receive appropriate training. • … (AI summary)
Response (HM Prison Probation Services.2): • The Introduction to Safer Custody course was replaced by the Introduction to Suicide and Self-Harm Prevention (SASH) course in May 2017. • The SASH course is delivered to all … (AI summary)
Responded
Kathleen Smith
Concerns: The coroner noted that Mrs Smith's family and the care provider's corporate risk function were not informed of her hip fracture's details, limiting investigation and learning. There was no audit of incidents following the departure of the manager responsible for internal reporting, despite documentation allegedly going missing.
Response (Borough Care): • Borough Care devised a form for managers to complete weekly to inform the Head of Care of significant incidents. • The new form was introduced to all managers on … (AI summary)
Responded
Paliben Dullabh
Concerns: The hospital does not have out-of-hours reporting arrangements for x-rays, though similar provisions exist for CT and MRI scans.
Response (paliben dullabh): • The Trust is implementing a solution to enhance surgical doctor cover at night. • A new staffing model will include substantively appointed registrars and an additional Senior House Officer … (AI summary)
Responded
Agnes Lambert
Concerns: The coroner noted that senior staff did not insist on a nurse moving wards despite a patient's fixation, which later contributed to an incident. Additionally, there was an unacceptable four-month delay in conducting witness interviews for a subsequent disciplinary hearing.
Response (Camden and Islington NHS Trust): • The Trust has appointed a permanent ward manager and is implementing "vital conversations" training for line managers to support challenging staff conversations. • The disciplinary policy is under review … (AI summary)
Responded
John Duckenfield
Concerns: The coroner noted false assertions by staff regarding patient observations and GP calls, a failure to record vital observations, and that the care home's records were inaccurate and misleading.
Response (Brancaster Care Home): • A new procedure for resident observations and their recording was implemented. • All registered nurses received training on contemporaneous record-keeping and NMC guidelines in January 2019. • Monthly audit … (AI summary)
Responded
Tina Tait
Concerns: The coroner notes concerns regarding the poor quality, illegibility, and storage of clinical records within the Trust. These issues compromise the effectiveness of incident reviews and the quality of patient care during handovers, a matter previously raised.
Overdue
Peter Carroll
Concerns: The coroner noted the absence of a leading physician to sign off reports and identified a six-month delay in reporting, which meant a curable treatment option was no longer available.
Response (Manchester University NHS Trust): • Processes in Histopathology and General Surgery were strengthened to ensure responsible physicians sign off reports. • A new system for managing paper histology results was implemented, including date stamping, … (AI summary)
Responded
Sidney Baker
Concerns: The coroner noted a lack of contemporaneous documentation for referrals and inaccuracies in the patient's care plan, including vital weight monitoring information. Concerns were also raised about the generally poor quality of record-keeping.
Response (Rosewood): • The home stated it maintains an Accidents and Incidents file, including falls and near misses, with weekly monitoring by management and monthly audits by the Regional Manager. • The … (AI summary)
Response (CQC): • The Care Quality Commission (CQC) completed a comprehensive inspection of the service in January 2020. • The inspection identified potential breaches of regulations related to record keeping, staff training, … (AI summary)
Response (Wigan Council): • Wigan Council confirmed that the recording of referrals, including those to dieticians and falls teams, has improved, with new procedures for documentation and follow-up. • The Council noted improvements … (AI summary)
Responded
Monica McCormick
Concerns: The coroner noted that clinicians did not complete a suspected cancer upgrade form and the pathology report was not communicated to the GP upon discharge. This, along with insufficient consideration of medical records, led to a delayed referral for chemotherapy.
Response (Northern Care Alliance NHS Trust): • Cancer services developed a standard operating procedure for new unsuspected cancer pathology to ensure patients are added to the cancer tracking database. • The Trust will discuss the importance … (AI summary)
Response (Northern Care Alliance NHS Trust): • Cancer services developed a standard operating procedure for New Unsuspected Cancer pathology to ensure all cancer diagnoses are added to the cancer tracking database. • The Trust stated it … (AI summary)
Responded
Sameena Javed
Concerns: The coroner noted the GP practice lacks a written procedure or guidance for administrative staff on triaging incoming correspondence, potentially leading to medical staff not seeing communications requiring action.
Overdue
Margaret Greenacre
Concerns: The coroner noted delays in statutory notifications of incidents to the CQC, including one that was never reported, potentially hindering investigations. Concerns were also raised regarding poor record-keeping at the care home, where care notes did not accurately reflect residents' needs and care plans were not updated.
Response (Alcyone Healthcare): • The care home is transitioning to a new provider and management team. • The new management team stated it would implement new compliance systems, reporting processes, and care planning … (AI summary)
Responded
Peter Ross
Concerns: Concerns were raised about a misreported CT C-spine scan, a reviewing surgeon's failure to note or escalate an abnormality, and the neurosurgical team not reviewing images before surgery. This was compounded by repeated communication failures between clinical teams and poorly maintained clinical records.
Response (Barking, Havering and Redbridge University Hospitals NHS Trust): • The Radiology Department completed actions assigned within the Trust's Serious Incident recommendations and reviewed Mr Ross's scans. • The Neurosurgery Department sent a reminder to staff regarding C-spine injury … (AI summary)
Response (Department of Health and Social Care): • The Barking, Havering & Redbridge NHS Trust conducted a serious incident report and presented the incident at a Trust-wide Patient Safety Summit. • The Trust delivered proposed teaching sessions … (AI summary)
Responded
David Nash
Concerns: The coroner noted an unclear process within the primary care complaints team for ensuring clinical reviews are fully informed by GP practice rationale and for sharing review details back to practices and networks for learning.
Response (NHS England): • NHS England will remind all regional complaints teams to share a copy of final complaint responses with the provider(s) concerned. • NHS England will include a reference to the … (AI summary)
Responded
Peter Lawrence
Concerns: The coroner noted a clinician's approach of relying on memory for patient information instead of maintaining proper records, identifying this as a risk for future patients.
Overdue
Colin Gumm
Concerns: The coroner noted gaps in Adult Social Care's monitoring and follow-up over several years despite known self-neglect. Concerns were also raised about a safeguarding assessment that was prematurely closed based on limited information and without awaiting key reports.
Response (Lincolnshire County Council): • Lincolnshire County Council has reviewed its safeguarding processes for matters where concerns are raised after an adult's death. • The safeguarding team conducts limited fact-finding enquiries to ascertain whether … (AI summary)
Responded
Bency Joseph
Concerns: The coroner identified delays in prescribing and administering therapeutic medication for psychosis, including a failure to provide urgently prescribed medication. Concerns were also raised about the Trust's internal investigation, which did not involve the senior pharmacist or the family.
Response (Essex Partnership University NHS Foundation Trust): • The Trust's Director of Pharmacy and Service Managers for urgent care pathways are reviewing medication needs for services. • Resources are being developed for urgent care services to reinforce … (AI summary)
Responded
Alexander Blewitt
Concerns: The coroner highlighted concerns over the lack of effective recording for intravenous fluids in the emergency department, deficiencies in patient information management and documentation by medical staff, and the poor standard of the incident investigation report.
Response (Milton Keynes University Hospitals): • The Trust developed a 'short infusion' order within its electronic patient record system and a training video for staff to improve the recording of intravenous fluids in the Emergency … (AI summary)
Responded
Sam Taylor
Concerns: Herefordshire Council's communication process failed to contact the deceased, or approved contacts, prior to his death. His housing application was not progressed, preventing his vulnerability under the Housing Act 1996 from being established, and an effective system for identifying process failures was noted as needed.
Response (Herefordshire Council): • A new management structure has been implemented, bringing all specific housing services under a single management team. • Strengthened processes have been delivered, from first point of contact through … (AI summary)
Responded
Emily Corfield
Concerns: Adferiad lacked a system for retaining service user correspondence, which led to individuals being closed to the service. Communication was restricted to writing only, and waiting times for support were long due to resource limitations.
Response (Adferiad): • Adferiad implemented a new electronic information management system to store all correspondence and log all calls. • All staff received training on the new system, and the service specification … (AI summary)
Response (Betsi Cadwaladr University Health Board): • A communication outlining the referral process to liaison services was produced and issued to clinical teams. • The Mental Health and Learning Disabilities Liaison Psychiatry Services in Acute Hospitals … (AI summary)
Responded
Stephen Weatherley
Concerns: The coroner identified concerns regarding data recording and retention practices at HMP Thameside, including lost documents and incomplete records, and the absence of a written policy for suspected drug swallow incidents.
Response (HM Inspectorate of Prisons): • HM Inspectorate of Prisons conducted a full inspection of HMP Thameside in November 2021 and published reports detailing concerns and recommendations. • The Inspectorate stated that the information provided … (AI summary)
Response (HM Inspectorate of Prisons): • HM Inspectorate of Prisons stated the information provided by the Coroner would feature significantly in its assessment of risk at HMP Thameside. (AI summary)
Response (Serco 1): • The prison has implemented a system for data retention using MS Teams folders and conducts daily Quality Assurance audits. • Independent audits of document retention and PNOMIS files have … (AI summary)
Response (HM Prison and Probation Service): • The contract for HMP Thameside includes specific delivery indicators for the management of records and data retention. • The prison's performance is reviewed monthly and during quarterly contract reviews, … (AI summary)
Responded
Ronald Harris
Concerns: Concerns included incomplete triage documentation and a promised follow-up call not being made. The triage doctor lacked awareness of appointment waiting times and relevant call transcripts, and a revised protocol for mental health patient triage had not been implemented.
Response (Hereford Medical Group): • Hereford Medical Group implemented a new process allowing clinicians to listen to phone calls if an online form is unavailable. • The group updated reception protocols to ensure patients … (AI summary)
Responded
Jennifer Campbell
Concerns: The coroner raised concerns regarding the absence of a formal investigation into a lost ERCP referral, which prevented learning and improvement. There was also a lack of audits for other lost referrals and delays in fully implementing electronic referral systems, posing patient risks.
Response (Betsi Cadwaladr University Health Board): • A new standing operating procedure for all endoscopy referrals was implemented in November 2023. • A full review of the incident process is underway, with a new process and … (AI summary)
Responded
Thomas Ithell
Concerns: The coroner noted a lack of Datix reporting and investigation into how a patient was lost to follow-up. Concerns were raised regarding staff time restraints and the Datix system's usability hindering internal governance processes.
Response (Betso Cadwaladr University Health Board): • An incident report was raised, a rapid review completed, and a full investigation is underway, with a report due by May 2024. • A revised training programme for the … (AI summary)
Responded
Thomas Loxton
Concerns: Administrative errors causing distress through post-death letters revealed insufficient collaborative working on death notification between trusts. Both trusts also had outstanding Root Cause Analysis recommendations with delayed completion dates.
Response (Dudley Integrated Health and Care NHS Trust): • Dudley Integrated Health and Care NHS Trust implemented an enhanced process for notifying patient deaths, including routinely contacting Black Country Healthcare NHS Foundation Trust (BCH) upon an unexpected death. … (AI summary)
Response (Black Country Healthcare): • The Trust provided an updated action plan detailing the completion status of learning objectives from its investigation. • Black Country Healthcare stated it has implemented an enhanced process for … (AI summary)
Responded
Nesta Jones
Concerns: The coroner identified a risk of missed diagnoses due to junior doctors not challenging consultant opinions, alongside inadequate urgent patient complaint systems and a lack of full investigation into the death.
Response (Betsi Cadwaladr University Health Board): • A Safety Alert will be issued by the end of April 2024 to support the improvement of listening to differing professional views. • A full review of the complaint … (AI summary)
Responded
Keith Smith
Concerns: The GP surgery could not demonstrate improvements in procedures, staffing, or training for recording patient calls, escalating enquiries to GPs, and monitoring GP call-backs to patients.
Response (Church Elm Lane Medical Practice): • The practice conducted training sessions to emphasize the use of an auditable message book for call escalation and direct communication with doctors for urgent concerns. • A Lead GP … (AI summary)
Responded
Select committee recommendations(248)— showing 50 strongest matches
#21 —
Recommendation: The Government should make complaints processes more accessible for non-English speakers. This should include making complaints forms and their signposting available in the most common languages used by the courts, and proactively sharing information about the complaints process with people …
Response attribution not verified
#20 —
Recommendation: Currently, the very people interpreting services are intended to support face a language barrier submitting complaints about interpreting services. This must urgently be addressed.
Response attribution not verified
#19 —
Recommendation: The Government should clarify where responsibility sits for submitting complaints regarding problems in interpreting in the courts, and should publish data on who submits complaints, for example whether they are a judicial office holder, HMCTS staff, a legal representative, or …
Response attribution not verified
#18 —
Recommendation: The Government must urgently take steps to improve awareness of complaints systems among legal professionals so that they are able to raise concerns through appropriate channels. This awareness raising should consider the wider issues facing legal professionals which prevent them …
Response attribution not verified
#17 —
Recommendation: The Government’s data on complaints significantly underrepresents the number of problems seen in the courts, due to low awareness, poor communication of the system, and cultural barriers among legal professionals. As complaints can result in interpreters being re-assessed or barred …
Response attribution not verified
#32 —
Recommendation: The introduction of national standards should be accompanied by a single national complaints and incident reporting portal for taxi and private hire services. It should be digitally inclusive, route reports to the responsible authority, and include clear service standards for …
Response status not verified
#31 —
Recommendation: Complaints and incident reporting arrangements are fragmented. In some areas they are difficult for passengers and drivers to navigate, reducing transparency and weakening accountability. (Conclusion, Paragraph 112)
Response status not verified
#5 —
Recommendation: The Department lacks good enough data to understand the nature and extent of problems renters face. The Department lacks sufficient data on the challenges facing landlords, tenants, and local authorities within the sector. For example, it lacks robust data on …
Response attribution not verified
#16 —
Recommendation: The Department received 6,521 complaints about child maintenance (around six for every 1,000 customers) in the year to 30 September 2021. This was considerably down from pre-pandemic levels in line with a general fall in complaints to the Department during …
Response attribution not verified
#29 —
Recommendation: We recommend that the Government legislate through the Social Housing (Regulation) Bill to place a legal requirement on social housing providers to self-assess against the Housing Ombudsman’s complaint handling code and to report to the ombudsman when they have done …
Response attribution not verified
#27 —
Recommendation: The introduction of the Housing Ombudsman’s complaint handling code and complaint handling failure orders must drive improvement and consistency in the way providers respond to complaints. We are pleased therefore that the Government is legislating through the Social Housing (Regulation) …
Response attribution not verified
#21 — Analyse complaint data to identify systemic issues and report quarterly on service improvements.
Recommendation: Users of such a service must receive assurance that information about complaints and failures is being aggregated and used proactively to improve systems and services, not just to effect redress to the individual. In order to achieve this, the Department …
Response attribution not verified
#26 — Reducing Energy Ombudsman escalation time risks increased caseloads, slower resolutions, and higher consumer bills.
Recommendation: We have reservations about the Government’s proposal to reduce the time before a case can be escalated to the Energy Ombudsman from eight to four weeks. This would likely inflate the volume of cases referred to the Ombudsman, which might …
Response attribution not verified
#15 — Clarify commission complaint procedures for maladministration and Police Ombudsman's investigative powers over state actors.
Recommendation: The Joint Framework and Troubles Bill partially fill the gap in commission accountability left by the Legacy Act. It is still unclear, however, what procedure there is to complain about maladministration or service failure by the commission. The Government must …
Response attribution not verified
#19 — Review support for NHS Muslim staff to ensure protection and effective reporting of abuse.
Recommendation: In light of increases in anti-Muslim hate in society, the NHS should review the support available to its Muslim staff and ensure that staff feel protected and able to report abusive and discriminatory behaviours in the knowledge that the necessary …
Response attribution not verified
#9 — Mandate regional mayors to lead awareness and trust-building for anti-Muslim hate reporting services.
Recommendation: Given reforms to the provision of local services, including the proposed abolition of police and crime commissioners, we recommend regional mayors take a lead role in working with community organisations to raise awareness of the reporting service, to build trust …
Response attribution not verified
#8 — Third-party reporting mechanisms for anti-Muslim hatred are vital and require inclusivity.
Recommendation: We welcome the Government’s introduction of a new fund to support a third-party reporting mechanism for victims of anti-Muslim hatred. Such mechanisms can play a vital role in enabling individuals to report hate crimes, particularly in cases where mistrust of …
Response attribution not verified
#5 — Significant underreporting of intersectional hate incidents against Muslim women hinders effective intervention.
Recommendation: The significant underreporting of hate incidents against Muslim women is a concern, and a barrier to it being tackled. Reasons for underreporting are various but include a lack of awareness of and confidence in the process. It is essential that …
Response attribution not verified
#12 — Confusing and poorly handled patient complaints system hinders early resolution efforts.
Recommendation: The 2025 Dash review of patient safety found that the current system for raising complaints and concerns is confusing, with issues often poorly handled and patients subject to delays and poor-quality responses. Research commissioned by NHS Resolution found that improving …
Response attribution not verified
#2 — Establish a national framework for patient safety with clear targets and improved complaints system.
Recommendation: The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing …
Response attribution not verified
#26 — AIRE service lacks follow-up mechanisms, creating accountability gap for complaints
Recommendation: Migrant Help is not contracted to follow up on or monitor issues and does not have sight of the response from providers and the Home Office. This creates a significant gap in accountability. We recognise the value of enabling asylum …
Response attribution not verified
#2 —
Recommendation: In May 2020, the PHSO reported to the Committee that it had experienced an increase of 13 per cent in demand compared to the previous financial year. Due to the introduction of a new digital casework management system, comparisons between …
Response attribution not verified
#1 —
Recommendation: The information provided in the PHSO’s annual report on the outcome of enquiries and complaints should be made more transparent. The grouping of cases that “are not ready to be taken forward” and “should not be taken forward” should be …
Response attribution not verified
#22 —
Recommendation: The Local Government and Social Care Ombudsman expressed concerns about its oversight of combined authorities, pointing to uncertainties over its jurisdiction and a loss of oversight when unitarisation occurred. We agree that proper complaints procedures should be in place in …
Response attribution not verified
#7 —
Recommendation: The Committee recommends that the PHSO learns from and implements best practice at the Local Government and Social Care Ombudsman by publishing feedback scores about its service, split between those complainants who were happy with the result of their case …
Response attribution not verified
#6 —
Recommendation: The PHSO have improved the data output about their own performance in recent years, which the Committee applauds. Nevertheless, the Committee is of the view that even more open and transparent access to feedback data will enable external stakeholders to …
Response attribution not verified
#3 —
Recommendation: The PHSO should also consider developing and reporting against timeliness targets for each grade of “severity of injustice” to better monitor the impact of the backlog on higher category cases in Levels 3 to 6.
Response attribution not verified
#2 —
Recommendation: The PHSO should more clearly notify visitors to its website which cases are not being considered under this new policy and further update the Committee on the review outlined to the Committee during the oral evidence session. The PHSO should …
Response attribution not verified
#1 —
Recommendation: The Committee notes the actions taken by the Parliamentary and Health Service Ombudsman to ensure continuing services to the public in difficult and unprecedented circumstances throughout the pandemic. However, the Committee notes the substantial backlog which has developed as a …
Response attribution not verified
#17 —
Recommendation: Despite child maintenance having the highest rate of complaints within the Department, the Department upholds a lower proportion of complaints relating to child 21 Qq 124–125; C&AG’s Report, paras 5, 1.14, 3.10 22 C&AG’s Report, para 3.11 and 3.12 23 …
Response attribution not verified
#5 —
Recommendation: The Department is too willing to blame low levels of customer satisfaction on CMS customers being difficult to please, despite its own systemic customer service failings. It is disheartening that customer satisfaction is no better now than it was under …
Response attribution not verified
#36 —
Recommendation: We encourage all social housing providers and the Housing Ombudsman to adopt a co-ordinated strategy to increase awareness among tenants of the ombudsman. As part of that, providers should routinely send letters and leaflets specifically about how they can complain …
Response attribution not verified
#28 —
Recommendation: If they have not already done so, all providers must immediately review and where necessary improve their complaint handling processes. As part of this, all providers that have not already self-assessed against the ombudsman’s complaint handling code should immediately do …
Response attribution not verified
#26 —
Recommendation: The primary responsibility for resolving disputes between tenants and providers lies with the providers themselves, and yet too often their complaint handling processes are inefficient and obstructive. It is understandable if tenants sometimes conclude they have been specifically designed to …
Response attribution not verified
#9 —
Recommendation: In addition to the wider efforts to improve basic documentation, the Department told us that it had introduced measures such as spot checks by the principal private secretary to reinforce the importance of proper record-keeping in private offices. The Department …
Response attribution not verified
#17 —
Recommendation: Although the Electoral Commission has an overall strong record in relation to monitoring, investigations and enforcement, we were concerned by the individual cases of extremely lengthy investigations and poor communication raised throughout this inquiry. The Electoral Commission has said it …
Response attribution not verified
#11 —
Recommendation: Many customers went to their MPs for help: complaints received via MPs increased from 2,600 per year in the two years before the pandemic, to 26,800 in 2021–22. The DVLA explained to us that people were coming to MPs because …
Response attribution not verified
#29 —
Recommendation: The Committee is encouraged by five organisations that have volunteered to adopt the UK Central Government Complaint Standards. We urge the PHSO to continue to engage with Government Departments and public sector organisations to increase this figure, and to report …
Response attribution not verified
#23 —
Recommendation: It is unsatisfactory that data provided to this Committee has been subsequently revised. The PHSO should report back to the Committee on what steps it is taking to quality assure its data before it is published and used by the …
Response attribution not verified
#10 —
Recommendation: The Committee is concerned by the fact that the PHSO has not met any of its targets for the overall section Service Charter scores in the 2021–22 financial year. The Committee had previously understood that the scores were expected to …
Response attribution not verified
#6 —
Recommendation: We are concerned by the number of Level 1 and 2 cases that are not being considered by the PHSO due to the approach of prioritising health complaints using the severity of injustice scale. We recommend that the PHSO sets …
Response attribution not verified
#11 —
Recommendation: Teleperformance, the contractor responsible for HMPO’s customer support telephone line, failed to meet its service level agreement of answering 80% of calls within 30 seconds from March 2022 to July 2022. In May, it only managed to answer 14% of …
Response attribution not verified
#15 —
Recommendation: We deplore the poor historical state of record keeping by the Ministry of Justice, Post Office Ltd, the Crown Prosecution Service and Royal Mail Group. Action must be taken to mitigate the risk that individuals eligible to have their convictions …
Response status not verified
#15 —
Recommendation: The National Audit Office (NAO) found that, although each regulator sets rules and expectations regarding how companies communicate with customers, many customers still find it difficult to contact the company supplying them. For example, in 2024 only 64% of broadband …
#9 —
Recommendation: The Committee recommends that the PHSO should publish a target for responding to correspondence, and should track its performance against that standard and report to the Committee each year. (Paragraph 31) Value for Money
Response attribution not verified
#8 —
Recommendation: It is necessary for complaints to the PHSO to be time-limited, as there needs to be some level of certainty about when matters that could potentially be complained about can no longer be taken forward. However, the Committee’s view is …
Response attribution not verified
#7 —
Recommendation: The PHSO should report regularly in its annual report the number of cases in the queue for allocation to a caseworker and the average amount of time it took for cases to be allocated to a caseworker. This will be …
Response attribution not verified
#6 —
Recommendation: The PHSO should provide a breakdown of how long health cases that are over one year old have been open for. This information should also be produced next to the general information the PHSO provides on the amount of time …
Response attribution not verified
#5 —
Recommendation: The PHSO should report in its annual report and accounts the number of new enquiries and complaints that have been received in that financial year. This number is separate from the number of enquiries and complaints that the PHSO has …
Response attribution not verified
#4 —
Recommendation: The Committee appreciates that there is a risk that complainants could be overwhelmed with information if all the evidence the PHSO has collected is shared with them, but it remains the case that complainants need to be assured that all …
Response attribution not verified
HSSIB safety recommendations(6)
Digital tools for online consultation in general practice
National healthcare organisations can improve patient safety by supporting general practices to report patient safety incidents associated with the use of online consultation tools.
Safety Observation
Temporary staff – involvement in patient safety investigations
If an incident takes place, how do you ensure that temporary staff are able to record it?
Learning Prompt
Temporary staff – involvement in patient safety investigations
How do you ensure that temporary staff are aware of how to record patient safety incidents?
Learning Prompt
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
HSIB recommends that NHS England ensures any Single Service contract or additional services contracts reflects the minimum requirements of the core NHS 111 service for audio-recording calls.
Safety Recommendation
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
Organisations that provide temporary staff to the NHS can improve patient safety by including information about the NHS England Learn from Patient Safety Events service to temporary staff as part of their onboarding process. This is to enable temporary staff …
Safety Observation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have processes for effectively feeding back concerns and incidents to secondary care when discharge communications do not meet your needs?
Learning Prompt
CQC inspection actions(166)— showing 50 strongest matches
William Harvey Hospital
The trust must operate an effective complaints procedure which includes providing timely responses and updates to complainants.
Must Do
University Hospital of Hartlepool
The trust must ensure that it operates effective systems and processes for identifying, receiving, investigating and responding to complaints.
Must Do
The York Hospital
The trust should consider ensuring all recording and timelines for grievances and disciplinary processes are a complete and contemporaneous record.
Should Do
The York Hospital
The trust must ensure that complaints are responded to in a timely way, result in further investigation if indicated and where possible involve family in the investigation.
Must Do
Scarborough Hospital
The trust should consider ensuring all recording and timelines for grievances and disciplinary processes are a complete and contemporaneous record.
Should Do
Scarborough Hospital
The trust must ensure that complaints are responded to in a timely way, result in further investigation if indicated and where possible involve family in the investigation.
Must Do
Royal Victoria Infirmary
The trust should consider ensuring all recording and timelines for grievances and disciplinary processes are a complete and contemporaneous record.
Should Do
Rochdale Infirmary
The trust should ensure that information to provide feedback, including how to complain, is clearly displayed in all areas.
Should Do
Rochdale Infirmary
The service should ensure it takes action to improve the timeliness of patient complaint responses to within the timescales specified in the trust complaints policy.
Should Do
Rochdale Infirmary
The trust should ensure complaints are investigated and responded to in accordance with the relevant policy and best practice.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must operate an effective complaints procedure which includes providing timely responses and updates to complainants.
Must Do
Princess Royal University Hospital
The trust must ensure complaints are handled in a timely way and in line with Trust policy.
Must Do
Princess Royal Hospital
The trust must ensure that it responds to all patient complaints as per their policy.
Must Do
North Manchester General Hospital
The trust should continue to improve the time taken to respond to complaints.
Should Do
North Manchester General Hospital
The trust should consider taking action to improve complaint response times.
Should Do
Northern General Hospital
The trust should ensure that information is widely displayed so that patients know how to complain.
Should Do
Northern General Hospital
The trust must ensure that complaints are responded to within timelines outlined in their policy and procedure.
Must Do
Mount Vernon Cancer Centre
The trust should ensure complaints are monitored and they are investigated and closed in a timely manner.
Should Do
Jessop Wing
The trust must ensure that complaints are responded to within timelines outlined in their policy and procedure.
Must Do
Fleetwood Hospital
The trust should ensure it continues to improve its complaints processes so that responses are compassionate, fully investigated in a timely way and reflective of the findings.
Should Do
Doncaster Royal Infirmary
The trust should continue to ensure that complaints are responded to in line with timescales set out in the trust policy.
Should Do
Doncaster Royal Infirmary
The trust should ensure it continues to operate effective systems to respond to complaints and take appropriate action without delay to any failures identified by a complaint or the investigation of a complaint.
Should Do
Castle Hill Hospital
The service must ensure that an effective and timely system for identifying, receiving, recording, handling and responding to complaints is clear to those raising concerns or making a complaint.
Must Do
Broomfield Hospital
The trust should ensure complaints are investigated and closed within the timeframes set out in the trust’s policy.
Should Do
The Walton Centre
The service should consider reviewing its arrangements for managing complaints to ensure complaints are responded to in a timely manner in line with trust policy and complaints receive an explanation of any delay in responding to their complaint.
Should Do
Fairfield General Hospital
The service should ensure it takes action to improve the timeliness of patient complaint responses to within the timescales specified in the trust complaints policy.
Should Do
Fairfield General Hospital
The trust should ensure complaints are investigated and responded to in accordance with the relevant policy and best practice.
Should Do
Fairfield General Hospital
The trust must take actions to improve the timeliness of patient complaint responses to within the timescales specified in the trust complaints policy.
Must Do
The Christie Main Site
The trust must ensure there is an effective process to manage complaints, in particular, ensuring the timeliness of responses.
Must Do
Sunderland Eye Infirmary
Review the practice of recording complaints in patients’ notes in line with best practice guidance.
Should Do
Royal Bournemouth Hospital
Complaints should be routinely investigated within the trust’s agreed timescales.
Should Do
Pinewood House
There continued to be delays between the patient submitting their complaint, and healthcare staff receiving it. For example, in December 2023, there was a delay of 20 days for one patient complaint, a delay of 19 days for 3 complaints …
Must Do
Durham Diagnostics and Treatment Centre
The service must monitor the reporting of staffing related incidents in an objective and reliable manner; and should consider implementing more robust (NICE ‘red flag’) recording and monitoring procedures that do not rely on individual reporting by staff.
Must Do
Dorothy Pattison Hospital
The trust should ensure staff completes incident forms and safeguarding alerts for all patients’ property that goes missing on the ward.
Should Do
Clifton Hospital
The trust should ensure it continues to improve its complaints processes so that responses are compassionate, fully investigated in a timely way and reflective of the findings.
Should Do
Berwick Infirmary
The department should work closely with the complaints department to ensure complaints are managed in line with the trust policy.
Should Do
Alnwick Infirmary
The department should work closely with the complaints department to ensure complaints are managed in line with the trust policy.
Should Do
Chy Byghan Residential Home
The provider must ensure people are provided with an effective and accessible complaint system.
Must Do
M N Pulse Solutions
improvement was needed to the records maintained such as to include dates and full detail about the incident and investigation.
Must Do
Kingfishers Nursing Home
The registered person failed to establish and operate effectively an accessible system for identifying, receiving, recording, handling and responding to complaints by service users and others in relation to the carrying on of the regulated activity.
Must Do
Heritage Healthcare-Middlesbrough
The provider must ensure complaints are investigated appropriately and dealt with effectively, with proper records maintained.
Must Do
Figtree Care Services Ltd
The provider and registered manager failed to ensure accurate records were kept.
Must Do
Winterton House
The registered person did not operate an effective system for identifying, receiving, recording, handling or responding to complaints.
Must Do
Park Grange Care Home
There was not an effective system in place to ensure concerns and complaints were recorded and responded to appropriately.
Must Do
Kingsley Nursing Home
The registered manager and provider failed to: 2. have an effective system to receive, record, investigate or respond to complaints. 16 (2)
Must Do
Kingsley Nursing Home
The registered manager and provider failed to: 1. investigate or take necessary action in response to complaints. 16 (1)
Must Do
Chatting Independently Limited - Rectory Drive
People who use the service could not assured that any complaints would be acted on investigated and resolved to their satisfaction.
Must Do
Barton Park Nursing Home
Complaints were not being recorded or responded to in line with the registered providers complaints policy.
Must Do
B&H Care Ltd
The provider must ensure people's complaints and concerns are managed effectively to promote their health, safety and wellbeing, including having a system for independent investigation of complaints and maintaining records of complaints.
Must Do
Ashmore House
The provider must establish and operate an accessible system for identifying, receiving, recording, handling and responding to complaints.
Must Do
HMICFRS recommendations(3)
FRS 2023-25 CoC Recommendations: Shropshire Fire and Rescue Service
Cause of concern: The service doesn’t have adequate processes, controls or internal governance arrangements in place to manage strategic risks, performance and improvement plans. Recommendation: The service should develop an action plan to make sure it has access to accurate …
Recommendation
An inspection of the service provided to victims of crime by Greater …
The force should immediately put in place arrangements to make sure that adequate supervision is applied to crime-recording decisions made by officers and staff.
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t taken sufficient action since the last inspection to appropriately resource its protection function. Recommendation: By 30 September 2021, the service should review its administration of the protection function to make sure it can record …
Recommendation
ICIBI immigration recommendations(18)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
An inspection of the Home Office’s use of sanctions and penalties
2. (Without waiting to complete any more comprehensive reviews), ensure that the quality and extent of record-keeping and data collection are sufficient to provide clear insights into the efficiency and …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
An inspection of General Maritime (October 2024 – February 2025)
Overhaul record-keeping in relation to general maritime, focusing on data quality, completeness and retrievability, in order to create and maintain an informed picture of GM threats, trends, actions and outcomes …
A further inspection of the EU Settlement Scheme (July 2020 – March …
Recommendation 8 Collect and publish data for complaints received in relation to the EU Settlement Scheme (EUSS) and for Administrative Review applications and outcomes.
An inspection of illegal working enforcement (August – October 2023)
Implement a standardised procedure for recording debriefing records on PRONTO.
An inspection of contingency asylum accommodation for families with children in Northern …
The Home Office should review the effectiveness of the advice, issues reporting and eligibility (AIRE) contract, in particular the processes for capture of complaints and feedback from those living in …
An inspection of the use of deprivation of citizenship by the Status …
Data recording - Review mechanisms for recording case data to ensure that record keeping is consistent, quality assured, and it allows for proper analysis to inform planning.
An inspection of contingency asylum accommodation (November 2023 – June 2024)
Improve record keeping and data quality by agreeing the requirements and minimum standards for information and data recorded by the Home Office and by the accommodation providers (and subcontractors) relating …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to IECA performance and productivity: a) Review record-keeping in relation to RG and CG decisions and identify how performance reporting could be improved to provide qualitative as well …
An inspection of General Maritime (October 2024 – February 2025)
Create and maintain a centralised record of what training every Border Force officer has completed and their training needs (including for refresher training), readily accessible to regions and commands, so …
An inspection of Border Force operations at Stansted Airport
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
An inspection of Border Force operations at south coast seaports
Record information about searches and other activities conducted by Border Force at and from each port in a consistent format and in sufficient detail to improve knowledge of the threats …
An inspection of Border Force’s fast parcels operations (May–July 2023)
Introduce a digital solution to record all fast parcels examinations in real time, including the reasons for examinations to provide managers with sufficient management information to plan and assure activity.
PPO death in custody recommendations(33)
The Governor of The Mount
The Governor of The Mount should ensure that all evidence, including electronic evidence, relevant to a death in custody is retained and made available to the PPO in line with PSI 58/2010.
The Governor of Isle of Man Prison
The Governor should ensure that the prison complies with its own policy for contacting the families of deceased prisoner and that they have adequately trained family liaison officers.
The Governor
The Governor should ensure that, following a death in custody, the family liaison officer (FLO) maintains an accurate log with all significant contacts and that the prison provide relevant documents when requested in line with PSI 58/2010.
The Director
The Director should ensure that family liaison officers record all family contact in the FLO log, including next of kin contact details, and provide it to the PPO investigator when requested.
The Governor
The Governor should ensure that all evidence about a death in custody, including electronic evidence, is retained and promptly made available to the Prisons and Probation Ombudsman, in line with PSI 58/2010.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that evidence is made available to the PPO, in line with PSI 58/2010.
The Governor
The Governor should ensure that prison staff provide all relevant information requested by the Prison and Probation Ombudsman’s office, in line with PSI 58/2010.
The Governor
The Governor should ensure that staff directly involved in a death in custody complete incident statements as soon as practicable following the death.
The Governor
The Governor should ensure that documents are retained, securely stored and promptly provided to the Prisons and Probation Ombudsman following a death in custody, in line with Prison Service Instruction 58/2010.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • All necessary paperwork explaining the decision to segregate is appropriately completed, stored, and made available in the event of a PPO investigation.
The Head of Healthcare
The Head of Healthcare should introduce a robust quality assurance process to ensure that prisoner applications are promptly responded to and healthcare staff record any action taken.
The Head of the National Approved Premises Team
The Head of the National Approved Premises Team should ensure that every death in an AP is subject to a local investigation and report similar to the process adopted in Southwest and South Central Region.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • prison staff record key information about their contact with prisoners on NOMIS, the prison records database, accurately and in a timely manner; and that • healthcare staff make contemporaneous records …
The NHS England – Southwest Commissioner
the NHSW Commissioner should inform the PPO of the outcome within six months.
The Governor
The Governor should ensure that all managers follow the national instructions for dealing with a death in custody or serious incident, including that all staff directly involved in an incident complete Incident Report Forms as soon as possible.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that the evidence is made available to the PPO, in line with PSI 58/2010.
The Head of Safety
The Head of Safety should ensure that there is a process in place for tracking and storing closed ACCT documents.
The Governor of HMP Hull
escort risk assessments are retained and stored securely in line with retention policies and General Data Protection Regulation (GDPR) requirements.
The Governor
The Governor should investigate what led to the documentation about Mr Boamah being lost and ensure that documentation is retained and stored securely in future.
The Head of Healthcare (HMP Erlestoke)
The Head of Healthcare should ensure that all contact and interventions with prisoners under the care of the substance misuse service are properly recorded.
The Governor
The Governor should ensure that documents are securely stored and promptly provided to the Prisons and Probation Ombudsman following a death in custody, in line with Prison Service Instruction 58/2010.
The Head of Healthcare
The Head of Healthcare should ensure that: formal care plans are in place to manage patients with chronic health conditions; and healthcare staff record the details and outcome of assessments in patients’ medical records; and follow the protocols for escalating …
The Director (HMP Peterborough)
The Director should ensure that the prison’s process for progressing and monitoring ERCG applications is reviewed so that applications are progressed in a timely manner.
The Governor
The Governor should ensure that staff directly involved in a death in custody complete incident statements as soon as possible after a death.
The Governor
The Governor should ensure that all information requested by the PPO following a death in custody is provided promptly.
The Head of Healthcare
The Head of Healthcare should develop a reporting tool to identify mental health referrals that are closed without action or explanation.
The Governor
The Governor should ensure that documents are securely stored and promptly provided to the Prisons and Probation Ombudsman following a death in custody, in line with Prison Service Instruction 58/2010.
The Governor of HMP Elmley
The Governor of HMP Elmley should review procedures for ordering monitoring tags for prisoners awaiting release, identify whether the error with Mr Corbett’s licence is a systemic issue and implement any necessary changes to mitigate this.
The Governor
securely retain risk assessment documentation.
Practice Plus Group
undertake a clinical audit of records made following an emergency response (after Mr Morgan’s death) to assess the quality of record keeping.
The Director of HMP Dovegate
The Director will want to ensure that managers continue to review and monitor the completion of these important interviews.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: review prisoners’ starting antidepressants in line with Royal College of General Practitioners’ guidance; record actions and decisions about a prisoner’s ongoing care in their medical record and check that the entries …
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should liaise with the hospital to develop a system to improve communication to ensure that changes in appointments are communicated effectively.
IOPC learning recommendations(27)
Investigation into response to a concern for welfare - Greater Manchester Police, …
The IOPC recommends that Greater Manchester Police takes steps to improve their record keeping and archiving around when changes are made to the Call Handling Minimum Standards. This could be achieved by way of implementing a version control system on …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should ensure that all staff involved in an investigation effectively document all policy decisions, investigative plans and lines of enquiry, ongoing progress, case reviews, and victim contact as part of the record of investigation. …
Recommendations - Metropolitan Police Service, August 2021
The IOPC recommends that the MPS DPS implements a system to monitor officer compliance with; - Record keeping procedures relating to decision making and; - Recording conflict of interests, either real or perceived to ensure they are recorded on their …
Recommendation - Surrey Police, April 2022
The IOPC recommends that Surrey Police updates relevant force policies relating to complaint handling [and body worn video (BWV) if appropriate] to include searching for BWV footage relevant to a complaint received and marking it as evidential as part of …
Recommendation - Lincolnshire Police, December 2022
The IOPC recommends that Lincolnshire Police should devise a unified, auditable process for handling unreasonable and unacceptable communications with service users. Consideration should be given to ensuring the process covers the needs of service users and how to fulfil them, …
Complaints made against a senior Lancashire police officer by two retired senior …
The IOPC recommends that Lancashire Police should ensure all policy decisions and rationales should be documented appropriately during the course of its investigations to record strategic decisions, operational priorities, and strategic, critical and investigative issues. This follows an independent IOPC …
Investigation into the West Yorkshire Police response to reports of injuries to …
The IOPC recommend that West Yorkshire Police (WYP) take steps to ensure that all officers and staff complete a NICHE (Occurrence Entry Log) with all relevant information OEL following a potential complaint of a crime and to ensure that all …
Man dies on way to custody - Thames Valley Police, November 2017
Officers in this case were not separated and were permitted to turn off their body-worn video (BWV) for the journey to the police station for the post incident procedure. This means that there is no record of any discussion that …
Recommendation - West Yorkshire Police, January 2026
The IOPC recommends that West Yorkshire Police implement a process for recording reasonable adjustments which a service user discloses to them, taking into account relevant data protection considerations. This follows a review where the complaint handler advised that the force …
Recommendations - West Yorkshire Police, February 2021
It is recommended that West Yorkshire Police (WYP) review their system for recording all radio transmissions in relation to authorised firearms deployments to ensure the actions and decisions of the Tactical Firearms Commander, Senior Investigating Officer, Authorised Firearms Officers and …
Recommendations - West Yorkshire Police, February 2021
The IOPC recommends that West Yorkshire Police (WYP) conducts a review of its scene management policies, procedures and training and where necessary make changes to ensure that where paper records are maintained those records are retained for production when required …
Recommendations - Suffolk Constabulary, October 2020
The IOPC recommended that Suffolk Constabulary takes appropriate action to satisfy itself that officers and staff are no longer completing multi-cell observations records and are complying with any change to force practices. This follows a DSI review in respect of …
Recommendations - Suffolk Constabulary, October 2020
The IOPC recommended that Suffolk Constabulary ensures that all custody officers and staff are reminded of the importance of accurate custody entries, and are made aware of any change to force practices concerning the recording of visits and observations. This …
Recommendations - Suffolk Constabulary, October 2020
The IOPC recommends that Suffolk Constabulary should stop the practice in its custody suites of making multi-cell observation records in individual detainee custody records. Entries on an individual custody record should only note observations in relation to that specific detainee’s …
Recommendation - Metropolitan Police, October 2020
The IOPC recommends that the Metropolitan Police Service create a policy for officers and staff to record ad hoc telephone conversations with victims of crime, post charge of a suspect. The policy should allow officers to re-open Crime Reporting Information …
Recommendation - Sussex Police, February 2021
The IOPC recommends that Sussex Police ensures formal guidance and policies are in place in relation to the storage of both physical and electronic investigative material obtained during an investigation, if it is not already, ensuring a consistent approach which …
Recommendations - Cleveland Police, February 2021
The IOPC recommends Cleveland Police assess whether it is feasible to provide a solution to enable members of staff to record the reason for checks when they are not directly involved in an incident. The Niche administrator for Cleveland Police …
Man died while in police custody – Nottinghamshire Police, June 2017
The IOPC recommends that Nottinghamshire Police remove the option of a drop-down menu when entering cell observation entries onto the custody log, or otherwise introduce a prompt to the system which reminds detention officers of the need to input further …
Investigation into police contact before death - Devon and Cornwall Police, July …
The IOPC recommends that Devon and Cornwall Police ensure that the time a check is conducted on a prisoner is recorded on the custody record in addition to the computer generated time shown when the update is added. The detention …
Recommendations - Wiltshire Police, September 2021
The IOPC recommends that Wiltshire Police reviews its document management and record keeping practices in relation to the Domestic Violence Disclosure Scheme (DVDS) to ensure that all research undertaken is recorded and the rationale for any decisions made is recorded, …
Recommendations - Bedfordshire Police, July 2021
The IOPC recommends that Bedfordshire Police reviews the current process of medical examinations being documented on paper records when problems are encountered with the Athena system, to ensure that copies of the paper records are shared immediately with custody sergeants …
Recommendations - Metropolitan Police Service, July 2021
The IOPC recommends that the Metropolitan Police Service (MPS) should conduct a formal review of the custody procedures regarding the safekeeping of seized evidence before it enters an evidential store. It is important that the procedures in place are sufficiently …
Reports of domestic incident prior to child sustaining serious injuries - Greater …
The IOPC recommends that GMP reminds control room staff of the importance of accurately recording information provided during calls so that it can be communicated to attending officers and used to inform decision making and incident management. A number of …
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that Hampshire Constabulary takes steps to ensure the microphones covering the booking in desks are in good working order, to ensure information communicated at the booking in desks is audibly captured. In addition, the force should review …
Recommendation - West Yorkshire Police, February 2020
The IOPC recommends that West Yorkshire Police amend their Standard Operating Procedure called ‘Forensic examination of digital devices and electronic networks – supporting information document’ to say that, if a memory device is left in computer equipment at the time …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police implement a supervision policy around the closure of incident logs. In this particular case, two staff members were not clear as to who could close an incident where the original classification code was different …
Recommendation - West Yorkshire Police, March 2023
The IOPC recommends that West Yorkshire Police (WYP) amends or creates policies and procedures in respect of acknowledging receipt and return of evidence from members of the public to ensure that they include a strategy for the receipt and return …
NAO audit recommendations(16)
Child Maintenance Client Funds Accounts 2020-21: 1993 and 2003 Schemes Account
For the 1993 and 2003 schemes, the Department should continue to review the service it is providing to parents and ensure that it: • maintains adequate records and has a clear process to support parents who have concerns around the …
Accepted
Child Maintenance Client Funds Account 2019-20
For the 1993 and 2003 schemes, the Department should continue to review the service it is providing to parents and ensure that it: • maintains adequate records and has a clear process to support parents who are concerned that arrears …
Accepted
Child Maintenance Clients Fund Account 2018-19
• ensure adequate records and systems are maintained until all arrears are written off or collected, and these schemes can be brought to a full close.
Accepted
Child Maintenance Clients Fund Account 2018-19
To improve customer service, the Department should: • establish a clear process to support parents who are concerned that arrears balances now being collected are inaccurate; and
Partially accepted
Investigation into NHS Property Services Limited
b) put in place an efficient dispute resolution process whereby all disputes are settled within 90 days of invoicing and agree a plan to clear outstanding disputes including a service-level agreement for responding to queries from tenants in a reasonable …
Partially accepted
Child Maintenance Client Funds Account 2019-20
To enhance accountability and reporting, the Department should: • take steps to ensure maintenance collected can be allocated to schemes and cases, to support accurate reporting and prompt payment to parents with care; and
Accepted
Investigation into NHS Property Services Limited
h) review its capacity to deal with queries in an effective and timely manner.
Accepted
Investigation into NHS Property Services Limited
The Department, in collaboration with national bodies and the Service should: a) develop a plan to ensure that the Service and all tenants of the Service’s premises will agree tenancy details and amounts by 31 March 2020; and
Accepted
Transforming health assessments for disability benefits
DWP should: b produce interim target operating models for the Programme at appropriate stages and continue to develop its test-and-learn approach including: putting in place the mechanisms to provide feedback to healthcare professionals and decision-makers and helping assure the consistency …
Accepted
Child Maintenance Client Funds Account 2021-22
allocates sufficient resource to provide appropriate customer service and timely responses to queries and complaints on cases
Accepted
Child Maintenance Client Funds Account 2021-22
maintains adequate records and has a clear process to support parents who have concerns around the accuracy of arrears balances that are now being collected
Accepted
Gambling regulation: problem gambling and protecting vulnerable people
f) review whether the arrangements for consumers when things go wrong are working effectively. This should include consideration of whether simplifying dispute resolution services would make it easier and more consistent for consumers to access them, and whether it would …
Accepted
Investigation into NHS Property Services Limited
g) continue to reduce the time it takes to issue bills; and
Accepted
DWP customer service
To improve its customer service, DWP should build its evidence base on the scale and type of avoidable customer contact, and develop a plan to improve its processes and communications in order to reduce avoidable contact and realise efficiency savings.
Accepted
DWP customer service
To improve its customer service, DWP should publish comprehensive reports which bring together annual performance, trends over time and whether it has exceeded or fallen short of its standards for its main customer service measures (customer satisfaction, payment accuracy, payment …
Partially accepted
DWP customer service
To improve its customer service, DWP should review the effectiveness of how it communicates claim-processing and call-waiting times to customers, and identify how it can provide fuller and more up-to-date information, at the point of claim and during other key …
Partially accepted
Victims' Commissioner recommendations(8)
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Ministry of Justice undertake a review of the victim journey with a view to exploring options for better delivery of Victims’ Code rights and communication, including exploration of a ‘single point of contact’ liaison or navigator that has …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: HMCPSI and HMICFRS jointly carry out a review of victim-facing communications, from the time the case enters the court system up to, and including, sentencing. This review should consider the quality and consistency of communications. Read recommendation detail Given …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The National Police Chiefs’ Council should issue guidance to Chief Constables to ensure that Witness Care Units/ police staff are undertaking thorough victim needs assessments, which fully recognise the impact delays in the court system can have on victim …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Crown Prosecution Service must ensure any additional vulnerabilities which could be exacerbated by delay are assessed by the Witness Care Unit/police staff and are then communicated as part of the plea and trial preparation hearings, and any subsequent …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Ministry of Justice must update the Victims’ Code to make clear that needs assessments should be ongoing during the court process. The effect of delay on the individual victim must also form part of that assessment in order …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Ministry of Justice commence the provisions in the Victims and Prisoners Act (2024) relating to victim information requests at the earliest opportunity, to ensure the new threshold for seeking notes of therapy is implemented. The Ministry of Justice …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The Crown Prosecution Service reviews and updates its guidance on pre-trial therapy to reflect the new threshold and to ensure CPS staff provide victims with accurate information about their rights, to help inform their decision about whether to proceed …
Justice delayed: The impact of the Crown Court backlog on victims, victim …
Recommendation: The National Police Chiefs’ Council update their guidance and the Soteria national operating model to ensure that police staff are aware of the new threshold and are able to provide victims with accurate advice on their right to access …
IMB annual reports(7)
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
Lindholme (2020)
HMP Lindholme is a Category C training prison with an operational capacity of 1,010. The report highlights improvements in security, segregation management, and some aspects of healthcare, including reduced GP waiting times. Key concerns persist regarding organised crime's impact on safety, substance misuse, delayed complaint responses, and the high number of IPP prisoners. Staffing, particularly for key worker roles and healthcare provision, continues to be an area requiring significant development.
PRISON
Key concerns
Yarl’s Wood (2021)
This IMB annual report for Yarl’s Wood IRC covers 2021, a challenging year marked by the Covid-19 pandemic and the transition to accommodate predominantly male detainees. The Board commends the centre's management for maintaining a safe environment with low Covid-19 cases, high quality healthcare, and generally fair treatment. However, significant concerns remain regarding the identification and support of vulnerable individuals, the clarity of induction for short-stay detainees, and the comprehensive tracking and resolution of complaints.
PRISON
Key concerns
Askham Grange (2024)
HMP/YOI Askham Grange is generally a safe and positive environment for women, with excellent staff-prisoner relationships, no self-harm incidents, and no use of force. While healthcare provision is good, concerns persist regarding accessibility and transparency of the complaints process, and issues with medication dispensing lockers. The prison excels in purposeful activity and resettlement, yet faces challenges with maintaining capacity and ensuring prisoners arrive with sufficient time to fully benefit from open conditions.
PRISON
Key concerns
Lindholme (2022)
HMP Lindholme continued to operate under COVID-19 restrictions, limiting regime and purposeful activity, yet saw the successful implementation of digital infrastructure and in-cell phones. While healthcare provision improved with reduced waiting times in most areas, significant concerns remain regarding persistent overcrowding, the high number of IPP prisoners, and the inadequate provision of resettlement services. Issues with the timely handling of prisoner complaints and property also need further attention.
PRISON
Key concerns
Wakefield (2022)
HMP Wakefield, a high-security prison for men, is generally considered safe but experienced increases in assaults and use of force. Key concerns include persistent issues with mental health transfers, a lack of robust healthcare complaints processes, and the absence of in-cell telephony. The Board also highlighted unsatisfactory property management and insufficient purposeful activity for prisoners.
PRISON
Key concerns
Peterborough (2025)
HMP/YOI Peterborough saw significant improvements in staff recruitment, regime delivery, and healthcare provision, with self-harm management remaining professional. However, the Board remains concerned about inconsistent and poor quality responses to prisoner complaints, poor professional standards among some managers, and persistent issues with medication distribution and social care referrals. The prison faces substantial challenges in adapting to a predominantly remand population for men and differentiating the women's regime.
PRISON
Key concerns
IMB individual recommendations(502)— showing 50 strongest matches
Onley (2020)
The speed with which prisoner complaints have to be dealt with often results in responses that have not been carefully considered. Prisoners need to have confidence in this process.
HMPPS
In Progress
Lindholme (2020)
Will the Governor ensure that prisoners’ complaints are dealt with in a timely manner and that, at the very least, a holding response is given to every complaint when it is received (see Survey Questionnaire 9b)?
Governor / Director
Lancaster Farms (2020)
There was a significant increase, in the second half of the year, in the number of complaints for which a response is overdue. This raises serious concerns regarding the allocation of resources to this activity (see paragraph 7.8).
Governor / Director
Berwyn (2020)
Responses to complaints (that is, Comp 1 and Comp 1a) are an issue in the establishment. If prisoners were kept informed of progress, it could reduce frustration, including additional Comp 1as and applications to the Board and the chaplaincy.
Governor / Director
Yarl’s Wood (2021)
The Board recommends that a centralised complaints-tracking database is introduced, to ensure that all complaints, regardless of the agency involved, can be shown to have been investigated within the allocated time frame and a reply sent to the complainant. The database should also link the complaint and response correspondence to each case and be accessible to agencies at the centre.
Home Office
Guys Marsh (2022)
The management of the complaints process improved markedly but responses to complaints continued to be disappointingly slow. Can the Governor assure the IMB that this will change in the immediate future?
Governor / Director
Bedford (2022)
Performance on complaints has got worse and prisoners tell us that they have little confidence in the system.
Governor / Director
Gatwick IRC (2023)
Review the complaints’ management systems for the healthcare unit to ensure there is adequate accountability to the men using the services.
NHS / Healthcare Provider
Gatwick IRC (2023)
Review the operation of the process for handling complaints against Serco, including factors behind withdrawal rates, considering changes such as introducing specialist teams to handle complaints, shortening the time for responses, and whether contractual penalties can be modified.
Home Office
Gatwick IRC (2024)
Provide more transparency about healthcare complaints and shorter timeframes for response. Provide adequate information to allow the IMB to assess the nature of the complaints and the effectiveness and efficiency of this complaints process.
NHS / Healthcare Provider
Rejected
Bronzefield (2024)
The number of complaints not answered within the timelines contained in the Prisoner Complaints Policy Framework continues to be of concern to the Board and has resulted in prisoners losing confidence in the system. What will the prison do to address this issue? (5.7)
Governor / Director
Yarl’s Wood (2020)
The Board recommends that, subject to the agreement of the complainant, the DES Complaints Team ensure all agencies fulfil their obligation to share complaints and their outcomes with the Board so that the Board can monitor the rigour of the investigation, and the timeliness and fairness of outcomes for detainees. The Board also recommends that all complaint resolutions are automatically …
Home Office
Wealstun (2020)
Ensure that Care UK has a process for replying to prisoner complaints within an agreed timescale (see paragraph 6.1.3).
Governor / Director
Thameside (2020)
The Director should overhaul investigations into prisoner allegations against staff, ensuring they are timely, reach meaningful conclusions, and provide valid responses to prisoners.
Governor / Director
In Progress
Manchester (2020)
What processes can be implemented to improve the quality of responses to those prisoners making a complaint?
Governor / Director
Belmarsh (2020)
Will the prison implement recommendations 26 and 27 of the 2017 Lammy Review in its handling of all complaints, not just discrimination complaints, and change the process for complaints to accommodate them (see section 5.7)?
Governor / Director
Bedford (2020)
Request that the healthcare team provides the Board and prison managers with monthly data regarding the number of complaints submitted to NHFT relating to the healthcare and mental health teams (separately).
Governor / Director
Swaleside (2021)
The Board asks the Governor to note the high level of applications we have received complaining about staff. These should have translated into complaints sent to him and the DDC, and are at a much higher level than last year. (see section 8)
Governor / Director
Send (2021)
The Board has identified that complaints in March 2021 have been stamped in batches indicating that boxes on wings were not being emptied nightly: this delay would impact on true response times (5.7).
Governor / Director
Huntercombe (2021)
For a more robust audit system to be operated as regards the complaints log, and for complaints beyond their response date to be consistently pursued (paragraph 5.7.2.).
Governor / Director
Hewell (2021)
Improve the handling of prison complaints and applications systems, focusing particularly on those which raise issues of discrimination, to ensure that such concerns are appropriately addressed and where necessary dealt with through the DIRF process.
Governor / Director
Belmarsh (2021)
Will the prison review the prisoner complaints process, as suggested in the IMB Annual Report of last year (see section 5.7 Complaints)?
Governor / Director
Wakefield (2022)
In our 2020-21 annual report we asked HMPPS to clarify if the complaints procedure for healthcare provision at HMP Wakefield is audited in line with standard complaints made under the COMP1/2 procedures. The Board is not satisfied with the procedures for dealing with prisoner complaints (or concerns). We ask HMPPS to clarify what action is being taken to remedy this …
HMPPS
In Progress
Preston (2022)
The backlog of Comp 1 forms needs addressing.
Governor / Director
Oakwood (2022)
During the reporting year the Board has been concerned that the healthcare complaint boxes were not emptied on a regular basis and their location is not easily accessible to all prisoners at all times. The Board asks the Director to review this with the head of healthcare (see para 6.1).
Governor / Director
Lindholme (2022)
We recommend that the matter be reviewed in order to improve prisoners’ confidence in the complaints system.
Governor / Director
Gatwick IRC/RSTHF (2022)
Share the contents of complaints against Healthcare, having redacted clinical information, and responses to them (sections 5.7, 6.1).
NHS / Healthcare Provider
Gatwick IRC/RSTHF (2022)
Share the contents of complaints against the Home Office, and their responses (section 5.7).
Home Office
Frankland (2022)
What actions are in place to improve the complaints response times?
Governor / Director
Downview (2022)
The Board has little confidence in how healthcare complaints and concerns are managed and logged and we hope to see a more efficient system being developed.
Governor / Director
Sudbury (2023)
The Board has noted a substantial number of complaints which were not processed by the deadline. What measures can be put in place to address this?
Governor / Director
Parc (2023)
Ensure the complaints system functions and monitor that responses are received within the required time scales.
Governor / Director
Oakwood (2023)
Can the Director consider what further steps can be taken, in addition to quality checks that are already being carried out, to improve the quality and legibility of the responses to complaints? Some replies neither address the complaint nor indicate what follow up has been completed.
Governor / Director
Liverpool (2023)
Prisoners are not receiving responses to complaints from other establishments within the timeframes specified in Prison Service policies. Some prisoners have been waiting for more than two years. What will the Prison Service do to ensure that this inadequacy is addressed and prevented?
HMPPS
In Progress
Littlehey (2023)
There has been a noticeable increase in the number of complaints at HMP Littlehey. The Board would like to be made aware of the processes in place to identify any trends in these complaints.
Governor / Director
Hewell (2023)
Monitor complaints by prisoners more rigorously, note the wide variation and quality of responses from staff, in particular the tone, an indicator of whether the desired culture change is being achieved throughout the prison. Improve the thoroughness of recording and responding to complaints about staff behaviour.
Governor / Director
Gatwick IRC (2023)
Share the contents of complaints against the healthcare unit, having redacted clinical information, and responses to them.
NHS / Healthcare Provider
Gatwick IRC (2023)
Share the contents of complaints – and their respopnses – against the Home Office.
Home Office
Downview (2023)
We reported previously that it was difficult to monitor the levels of complaints within healthcare as the system of recording appeared not to function adequately.
Governor / Director
Coldingley (2023)
Complaints from prisoners provide a vital insight into aspects of prison life which are not working well. There is evidence that there are has been a deterioration in quality of response to complaints, with many prisoners stating 'there is no point'. What plans does the Governor have to improve the system and restore trust in the prisoners that they will …
Governor / Director
Bronzefield (2023)
How does the prison plan to ensure that complaints are handled in line with the Prisoner Complaints Policy Framework?
Governor / Director
Stoke Heath (2024)
Can prison complaints be answered clearly in a timely manner, by the right person and at the appropriate level?
Governor / Director
Pentonville (2024)
Will you commit to reinstate auditing of the quality of responses sent by the prison to prisoner complaints?
Governor / Director
London STHF (2024)
The Board is of the opinion that one person or a team should be made responsible for sending out a consolidated reply that incorporates replies to the complainant from all agencies.
Home Office
Coldingley (2024)
The DIRF system must be seen as fair and independent so prisoners feel confident to use it. Will an external auditor be appointed as soon as possible?
Governor / Director
Oakwood (2025)
Can the Director work with health champions and members of the HAS Line, a prisoner-led initiative which works with Healthcare, to address the issue of the availability of health complaint forms on the houseblocks?
Governor / Director
Oakwood (2025)
Can the Director work with the Development and Assurance (D & A) department to address the issue of the availability of prison complaint forms on the houseblocks?
Governor / Director
Lindholme (2025)
The Board asks that a review be undertaken of submission and collection process for prisoner complaint forms (Comp1s, Comp1As/appeal forms, DIRFs/discrimination incident reporting forms) in order to raise prisoner trust and confidence.
Governor / Director
Lindholme (2025)
The Board asks that a review be undertaken of submission and collection process for prisoner complaint forms (Comp1s, Comp1As/appeal forms, DIRFs/discrimination incident reporting forms) in order to raise prisoner trust and confidence.
Governor / Director
Gatwick IRC (2021)
Operation of the process for complaints against Serco should be reviewed, including factors behind withdrawal rates, and this should consider changes such as introducing specialist teams to handle complaints, shortening the time for responses, and whether contractual penalties for substantiated complaints can be modified (section 5.7).
Home Office
Health investigations(106)
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec n.
That detailed records, including a careful note of dates and times, are kept whenever an approved social worker makes an application and delegates the power to convey the patient to hospital. A form should be devised for the purpose, and it should be attached to the application and the report …
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec k.
That, provided community mental health staff make an adequate record of client examinations and interviews (in the patient‘s medical, nursing or social work notes, etc), keep their CPA documentation up-to-date, and complete any audit records required of them, they should not be required to complete any other documentation.
midlands
Independent investigation: Tracey Baker, Chard (2015) — Rec 1
A 12-month audit review should be undertaken to review the timescales of Somerset Partnership NHS Foundation Trust’s submissions of their serious incident reports to both the families and SCCG. The results of this audit review should be reported to the NHS England (South) Mental Health Homicide Lead.
south_west
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 20
The Trust should have a monitoring system in place to ensure that it is complying with Departmental guidelines on complaints procedures. Where the 85% target is not being met action should be taken to resolve delays. The response from the chief executive officer should outline the process the complainant may …
south_east
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 14
CMHT case discussions should be recorded in a similar manner to CPA meetings. Particular note should be taken of action plans and naming those responsible for their implementation.
south_east
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 13
A system of registration and inspection of counselling services needs to be put in place, not least to ensure adequate supervision and monitoring of cases referred to counsellors. Such a system should include ensuring that policies are in place concerning the recording of interviews and record keeping generally, confidentiality (and …
south_east
Independent investigation: Roy Barber, Chiswick (2006) — Rec Recommendation Three
In accordance with best practice and to ensure that staff have the opportunity to check that the evidence they have given to internal reviews is accurate and reflects the issues that they wish to raise it is recommended that all interviews undertaken for internal reviews are recorded and transcribed.
london
Independent investigation: Richard Price, Bromley (2009) — Rec 1.9.8
Details of contact with the patient, emails and letters by all CFT members should be uploaded to RiO in a timely fashion. Emails and letters can be uploaded directly into the progress notes, which can save time by avoiding writing a separate entry, and means that a coherent, chronological record …
london
Independent investigation: Lisa Sullivan, Walton on the Naze (2005) — Rec 9
The Trust should ensure that when complaints by service users are made and investigated, the process complies with the current Trust Policy and a complete record of that investigation is held corporately by the Trust and is not retained in local managers’ offices.
east_of_england
Independent investigation: Lesley Wright, Tooting (2006) — Rec R7
The trust should ensure that all team members maintain trust standards for case recording.
london
Independent investigation: Lesley Wright, Tooting (2006) — Rec R5
The trust should ensure that managers regularly audit records of team meetings to assess their quality and compliance with trust standards.
london
Independent investigation: Lesley Wright, Tooting (2006) — Rec R4
The trust should ensure that all CMHTs are given clear guidance on the standards for recording team meetings. Records of team meetings should show who attended, the range and content of discussion on individual cases and the decisions made by the team.
london
Independent investigation: Karen Godden, Leicester (2007) — Rec 6
LPT’s internal investigation report did not evidence that a reflective or analytical approach had been taken to the investigation of the MHSU’s care and management. Furthermore the report was written in a rather congratulatory style and this caused offence to Miss K’s family and to the family of the service …
midlands
Independent investigation: John Crook, Liverpool (2008) — Rec 2
The formulation of investigation reports Overall, the Trust’s investigation report was well structured. However, for future reports attention needs to be given to: The contents page also setting out the relevant page numbers The inclusion of a findings section which sets out clearly: A summary overview of the overall …
north_west
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R13
The trust should review the operation of the complaints system and systems supporting the investigation of incidents to ensure that service-users and carers receive timely information on their complaints and are fully included in discussions about their care (A).
midlands
Independent investigation: Aysel Djevdet, Palmers Green (2009) — Rec 2
The Internal Report identified that Mr H and a member of staff working in the ERC had concerns about mental health services in January 2009. To date these have not been investigated. It is recommended that the concerns raised are investigated and the outcome included for further action or consideration. …
london
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 7
SHFT should ensure that all complainants that go through its complaints handling process, have access to advocacy services where required. SHFT should be alert to the importance of perceived independence of representation. Therefore, it should look to Third sector organisations that it can to facilitate access or signpost their availability …
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 6
During the investigation of complaints, SHFT should offer the opportunity for face-to-face meetings as a matter of course. These meetings should provide the time to discuss with complainants about how they wish their complaint to be handled and a timeframe for a response, should be agreed. SHFT should maintain communication …
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 5
SHFT should re-develop its Complaints Handling leaflet that reflects the complaints process, outlines expectations and timelines for service users, family members and carers. It must be co-designed and co-produced with these groups. The documents should be widely available to all in paper and digital format.
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 4
SHFT should urgently implement a process to monitor the quality of the investigation of complaints, complaint reports and responses and the impact of recommendations from complaints. That system should test the extent to which outcomes and judgments are evidence-based, objective and fair.
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 2
SHFT should clarify what complaints management system is actually in place in the organisation, whether this is centralised or locally managed, and further go on to ensure the system is publicised and shared in clear language with staff, service users, family members and carers.
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 1
SHFT’s Complaints, Concerns and Compliments Policy and Procedure documents should be urgently reviewed and reformed. They should be combined into a single document. The policy should prioritise service users, family members and carers. SHFT should work with these groups to co-produce it. It must be clear, straightforward and in an …
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Independent investigation into the care and treatment of Mr L — Rec 5
The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about: the type of records to be created and stored when conducting an internal investigation; storage and retrieval of clinical records, and reporting of misplaced clinical records, …
Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Accepted
Assurance Review: Trust recommendations — Rec 27
Managing complaints and compound family questions • The Trust’s Management Procedure for the Investigation and Resolution of Complaints should be reviewed to ensure advice is clear on the handling of persistent/compound complaints that are not vexatious. • Repeated approaches/compound questions from a family in relation to concerns in care, including …
north_west
An independent investigation into the care and treatment of Mr … — Rec 13
The Trust must ensure that communication from families is logged appropriately and that a timely response is given. The Trust must also ensure that information is given to carers indicating what other routes are available to them if they are not satisfied that their concerns are being taken seriously.
south_east
An independent investigation into the care and treatment of David: … — Rec 9
The Trust must complete the review of the complaint handling process and implement the recommendations from the review, incorporating particular reference to engaging with and listening to families.
David. At the time of his death David was receiving care and treatment from North West Boroughs Healthcare NHS Foundation Trust
north_west
An independent inquiry into the care and treatment of Ms … — Rec 2
Minimum recording standards should be introduced in relation to adult protection cases
south_east
An independent external quality assurance review of the independent investigation … — Rec 9
The Trust must complete the review of the complaint handling process and implement the recommendations from the review, incorporating particular reference to engaging with and listening to families.
David at North West Boroughs Healthcare NHS Foundation Trust
north_west
A post-publication assurance review in relation to the implementation of … — Rec B1
Trust Serious Incident (SI) Panel meetings should be formally recorded.
north_east_yorkshire
Tees, Esk and Wear Valleys NHS Foundation Trust, Quality Assurance … — Rec Two
TEWV should ensure that written responses to complaints fully address all of the concerns raised, and provide full explanations of resultant Trust actions.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr T — Rec 1
Given the difficulties we have experienced obtaining the information we required during the investigation process, the Trust should implement a clear policy for ensuring that requests for information from independent investigations are met in a timely and efficient way.
Mr T who committed a homicide in May 2014. Mr T was in receipt of services from Camden and Islington NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr B — Rec 16
The Trust must review the detail of the actions taken in response to the complaint made by Miss N to assure themselves that the failures in investigating and communicating in a timely fashion cannot be repeated.
Mr B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of DO — Rec 7
In order to ensure that the learning from the care and treatment of Donna in relation to the supervision of Trainee Psychiatrist 1 has been established, the Independent Investigation Team recommends that an audit be undertaken by the Trust of the following: 1. An audit of the complaints made against …
DO who committed a homicide in 2013. DO was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of DO — Rec 10
It is recommended that: 1) The Trust reviews its training requirements for individuals who are tasked with responding to complaints to ensure that the duty of openness is applied to all complaints, in order to ensure that all elements of complaints are addressed accurately. 2) The Trust reviews its complaints …
DO who committed a homicide in 2013. DO was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Mr … — Rec 4
The Trust should assure itself that concerns submitted by families or members of the public regarding a patient are documented, subject to assessment and review, and where appropriate proactively acted on. In instances where action is not taken, the rationale should be documented.
east_of_england
An independent investigation into the care and treatment of Emily … — Rec 7
Durham County Council must respond formally to serious concerns raised about the care and treatment of a young person under their care and explore those concerns with the family and young person.
An independent investigation into the care and treatment of Emily at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 20
TEWV should ensure that it improves its response to complaints, so that complaints are managed in line with NHS England best practice guidance – tracking and reporting this through the relevant Board subcommittee processes.
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent external quality assurance review of the independent investigation … — Rec 5
The Trust and Salford Royal NHS Foundation Trust must ensure that when recording that a patient is being treated under the Deprivation of Liberties Safeguards (DoLS) framework the appropriate documentary detail is in place to apply the Mental Capacity Act lawfully.
north_west
An independent external quality assurance review following an internal investigation … — Rec 1
Trust SI panel meetings should be formally recorded.
A in Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Independent investigation: Richard Marden, Towcester (1999) — Rec 18
That in the event of a Serious Untoward Incident, contacts with and offers of support to the victim's family, including telephone contacts, should be documented and recorded in the Serious Untoward Incident report sent to the Health Authority. Details of contacts and offers of support made subsequent to the preparation …
midlands
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.9
There should be a clear audit trail of the decisions and action points agreed at multi-disciplinary team meetings and of their implementation and outcome.
south_west
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 22
The panel recommends that the Trust review the Norfolk Mental Healthcare (NHS) Trust policy relating to Preservation, Retention and Destruction of Records within three months. (Paragraph 12.7)
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 14
The panel recommends to the Trust that the minutes of the CMHT meetings record clearly all decisions of the meetings and actions to be taken regarding patients. The minutes should identify the member who should take action and set an agreed time by which that member should report back to …
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 5
The panel recommends that the Trust ensures within three months that a copy of all the incident report forms for every inpatient and community incident is located in the relevant patient’s health and social care notes. (Paragraph 5.11)
east_of_england
Independent investigation: Amina Ali, Sheffield (2004) — Rec S6
where existing audits rely on the collection of data from the clinical record key aspects of the CNST requirements are incorporated. Examples of such requirements are that all entries are legible, and that all entries are dated with printed name/legible signature of author.
north_east_yorkshire
Independent investigation: Amina Ali, Sheffield (2004) — Rec S5
While SCT were able to evidence that an audit of medical documentation had occurred there appears to have been no audit of the quality of documentation across all professional groups. Given the issues identified regarding the quality of documentation in the case of S1 and the information shared with the …
north_east_yorkshire
Independent investigation: William Kean, Canning Town (2004) — Rec One
It is recommended in accordance with best practice and to ensure that staff have the opportunity to check that the evidence they have given to internal reviews is accurate and reflects the issues that they wish to raise that all interviews undertaken for internal reviews are recorded and transcribed verbatim. …
london
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Nine
It is recommended that the Trust reviews its clinical lead process on each ward and sets out a clear structure of responsibilities and the procedure to report concerns through the Trust’s governance system. All concerns should be documented, with agreed outcomes and the process to achieve these monitored and reported …
london
Independent investigation: Peter Hartley, Keighley (2001) — Rec 6.3.2
Consider how the Emergency Duty Team keeps records with reference to their personal notes.
north_east_yorkshire
Independent investigation: Peter Hartley, Keighley (2001) — Rec 6.2.7
Review of record keeping policy to include: ■ Practitioners must record date of next appointment when documenting records ■ List of agreed and recognised abbreviations to be included in policy ■ Printed surname & designation as well as signature
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
Article 2 learning points(13)
— LP 6
Archived records in accordance with PSO 9020 should be more clearly indexed to facilitate future investigations.
HMPPS
— LP 7
I recommend that NOMS reviews the guidance to establishments about action following life-threatening incidents of self-harm to ensure that it makes clear that evidence must be preserved.
NOMS
— LP 6
We draw to the attention of the Governor of HMP Chelmsford deficiencies in the collection, recording and preservation of evidence that we have found in this case.
The Governor
Accepted
— LP 2
If they have not already done so, NOMS and HMP Whitemoor should consider if current procedures and staff training provide for the full and accurate completion of official prison documents. Adequate audit and storage arrangements should also be considered as part of any subsequent review. The investigation highlighted a high …
NOMS and HMP Whitemoor
Accepted
— LP 11
Managers at HMP Birmingham should remind prison staff in contact with prisoners of the importance of documenting events in a prisoner’s Prison National Offender Management Information System record.
The Governor
Accepted
— LP 18
The list of documents to be retained as set out in PSI 15/2014 Investigations and learning following incidents of serious self-harm or serious assaults where an independent investigation will be necessary should mirror that in PSI 64/2011, Management of Prisoners at risk of harm to self, to others and from …
HMPPS
Accepted
— LP 17
All relevant documentation relating to a prisoner following an incident that may result in an investigation under Article 2 should be promptly secured.
HMPPS
Accepted
— LP 4
HMP Norwich should formally include a standing item on the safer custody meeting agenda to review progress on outstanding simple investigations.
HMP Norwich
Accepted
— LP 3
HMP Norwich should review its record keeping procedures to ensure documents are stored in a way that they can be retrieved and produced on request
HMP Norwich
Accepted
— LP 1
HMPPS should update PSI 15/2014 (which has an expiry date of 02 April 2018). Consideration should be given to: • requiring governors to complete any simple investigation within three months of the incident, or provide an update on the progress of the investigation at three monthly intervals • facilitating the …
HMPPS
— LP 3
HMP Featherstone should comply with the mandatory action contained in Prison Service Order 1300 – ‘Investigations’ that a formal investigation is completed when there is serious harm to any person.
HMP Featherstone
Accepted
— LP L
When prisoners raise medical issues in adjudications, the information should be passed on to the appropriate health care services.
HMPPS and PPG
— LP 6
When a prison security department receives critical security information from a sending establishment outside the prescribed timescales, this should be communicated to the Governor at the sending prison so that remedial action is taken to rectify any system failures.
HMPPS
Accepted
Detention investigations(13)
Investigation into the Failing of Medomsley Detention Centre — Rec 2
The second is around the complaints process for children in custody. I have made a notable observation that the system for children to make a complaint in today’s criminal justice system remains broadly the same as the system in place when Medomsley operated. To make a complaint, children must write …
Prisons
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 49
IND reviews complaint handling in removal centres with a view to establishing greater consistency. The review should take account of procedures for recording complaints. Records should show what the complaint was, when it was made, when resolved and what the resolution was.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 54
I recommend that IND establishes the office of Prisons and Probation Ombudsman on an administrative basis as the independent tier of its detainee complaints system as a matter of priority. The Ombudsman should be required expressly to act as guardian of the whole complaints system and funded accordingly.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R52
The SMT should ensure that a single log is kept of all allegations or instances of misconduct by staff and the actions taken in respect of them. (To be completed within 3 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 53
I recommend that a separate resource is identified and properly trained to handle complaints and associated work.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 1
I recommend that all complaints of racism at Oakington, however dealt with, are formally recorded.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 19
I also recommend that those who raise issues or grievances are given regular progress reports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 18
I recommend that senior managers ensure that strict deadlines are adhered to when progressing complaints and grievances.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 25
I recommend that the Home Office commission a formal review of the quality of PERs and that any deficiencies are addressed. In the meantime, all staff should be reminded of the importance of completing PERs fully.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 52
I recommend that a module on complaints handling and investigation is incorporated in the training package for contract monitors.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 24
The Home Offce should strengthen its data monitoring processes and quality assurance for the detention gatekeeper and case progression panels. In particular, it should ensure that the outcomes following case progression panels are tracked and reported.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 74
contractors be required to include in their contingency plans the steps they will take following an incident of this kind to ensure that detainees know how to claim for lost property. The plans should include the identity of a named individual who will be responsible for addressing and resolving all …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 48
I recommend that all contractors carry out ethnic monitoring of all complaints, overseen by the respective contract monitors.
Immigration Detention
Independent reviews(29)
Hodgson Charities Act Review — Rec 49
Individual charities should adopt and publish internal procedures for disputes and complaints. Umbrella bodies are ideally placed to support charities with this by the development of pro-forma procedures and support in their implementation, perhaps even taking on the role of adjudicator for their members.
Other
Francis Inquiry (Mid Staffs 2010) — Rec 6
The Board should review the Trust's arrangements for the management of complaints and incident reporting in the light of the findings of this report and ensure that it: provides responses and resolutions to complaints which satisfy complainants; ensures that staff are engaged in the process from the investigation of a …
Health & Social Care
Morecambe Bay Investigation — Rec 31
The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature of the failures and persistent comment from elsewhere lead us …
Health & Social Care
Morecambe Bay Investigation — Rec 13
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses to complainants. The Trust should increase public and patient involvement …
Health & Social Care
Leveson Criminal Courts Review — Rec 19
I recommend that trial and sentencing proceedings in the magistrates’ court be audio recorded and, if necessary for the purpose of appeals, appropriate parts transcribed.
Justice & Legal
Wessely Review — Rec 30
The Government and CQC should take steps to improve the systems that handle complaints from patients and their carers across providers, commissioners, police and local authorities to improve transparency and effectiveness across the system.
Health & Social Care
Accepted
Wessely Review — Rec 29
Information going to hospital Boards should be separated between complaints made by patients detained under the MHA and complaints made by informal patients.
Health & Social Care
Accepted
Wessely Review — Rec 27
Section 132 of the MHA should be amended to require managers of hospitals to provide information on making complaints to patients and their nominated person.
Health & Social Care
Accepted
Modern Slavery Act Review — Rec 13
There should be a formal complaints procedure in place [to ensure the Commissioner’s accountability and protect him/her from unjustified allegations]. The procedure should be clearly set out on the Commissioner’s website and should be a tiered procedure with the final stage of escalation independent of the sponsoring Department.
Justice & Legal
Accepted
Darzi Review — Rec 19
Patient engagement. The patient voice is not loud enough. The NHS should aspire to deliver high quality care for all, all of the time. That not only means care that is safe and effective but that treats people with dignity, compassion and respect, making their experiences as positive as they …
Health & Social Care
Ockenden Review — Rec LAfL 14.17
Improving Complaints Handling All staff involved in preparing complaint responses must receive training in complaints handling.
Health & Social Care
Ockenden Review — Rec LAfL 14.15
Improving Complaints Handling Complaint responses should be empathetic and kind in their nature. The local MVP must be involved in helping design and implement a complaints response template which is relevant and appropriate for maternity services.
Health & Social Care
Clementi BBC Governance Review — Rec 7
the BBC should have a 'Broadcaster First' system of complaints; appeal above the BBC on editorial issues would be to Ofcom
Other
Litchfield WCA Review Year 5 — Rec 3
The Explanation Call is removed from the mandatory reconsideration process, and that information on the points of contention are collated and included in the referral to dispute resolution teams where possible.
Employment & Work
Harrington WCA Review (Year 3) — Rec 2
Rather than an Appeals Officer re-writing the Reasoning valuable time and resources could be saved by adding necessary information to it and then submitting it. The DMs reasoning is then the backbone of the Department’s case for that claim, any reconsideration, and any appeal.
Employment & Work
Shawcross Review — Rec 34
Create a new standards and compliance unit answerable to ministers on the Prevent oversight board. The purpose of the unit should be to process and investigate complaints from Prevent practitioners and the wider public. Ministers can task the unit to conduct specific investigations and a summary of findings following investigations …
Policing & Security
Accepted
Ockenden Review — Rec 5
Clinical governance – incident investigation and complaints handling. Essential action: Incident investigations must be meaningful for families and staff and lessons must be learned and implemented in practice in a timely manner. • All maternity governance teams must ensure the language used in investigation reports is easy to understand for …
Health & Social Care
Accepted
Hodgson Charities Act Review — Rec 60
The Charity Commission should do more to support self- regulation - for example including the FRSB tick logo on member charities’ public register pages, asking at registration whether organisations are members of the FRSB, promoting the FRSB in communications to charities, and publicising for the public the FRSB as the …
Other
Litchfield WCA Review Year 4 — Rec 23
Review the guidance on the preparation of Reasoning and audit completed documents on a regular basis to further improve quality.
Employment & Work
Keogh Cosmetic Interventions Review — Rec 34
The remit of the Parliamentary and Health Service Ombudsman (PHSO) should be extended to cover the whole private healthcare sector, including cosmetic procedures and ophthalmology. Providers should offer advice on their complaints procedures to their patients, and where appropriate this advice should be available on their websites.
Health & Social Care
Goldacre Review — Rec Open 5
Create an Open Code Ombudsman and Assistance Unit It is possible, particularly whilst the NHS analytics workforce is in a transition period, that there will be occasions when an analyst or team of analysts in one NHS organisation needs access to code that has not yet been made open by …
Health & Social Care
Dearing Higher Education Review — Rec 60
We recommend to institutions that, over the next two years, they review and, if necessary, amend their arrangements for handling complaints from students, to ensure that: they reflect the principles of natural justice; they are transparent and timely; they include procedures for reconciliation and arbitration; they include an independent, external …
Education
Paterson Inquiry — Rec 6
We recommend that information about the means to escalate a complaint to an independent body is communicated more effectively in both the NHS and independent sector. We recommend that all private patients should have the right to mandatory independent resolution of their complaint.
Health & Social Care
Farmer Review (Men) — Rec 14
As part of their Performance Agreement each prison should establish a clear, auditable and responsive 'gateway' communication system for families and significant others: a dedicated phone line that is listened to and acted upon. • Families' concerns about mental and physical health should be systematically recorded and action taken. • …
Justice & Legal
Morecambe Bay Investigation — Rec 34
The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service Ombudsman over necessary action and follow-up. We recommend that a …
Health & Social Care
Harrington WCA Review (Year 3) — Rec 1
In order to improve the quality of decision making the Secretary of State for Work and Pensions asks the Tribunal Service for timely feedback on reasons for upheld appeals.
Employment & Work
Wessely Review — Rec 48
Where the tribunal believes that conditions of a patient's detention breaches the Human Rights Act 1998 they should bring this to the attention of the CQC (or HIW in Wales).
Health & Social Care
Accepted
Wessely Review — Rec 28
Staff dealing with complaints should have an understanding of the MHA so they are aware of the particular impact of detention.
Health & Social Care
Accepted
Wessely Review — Rec 26
Commissioning by local authorities should be strengthened, so that: a. guidelines make it clear that IMHAs are best placed to provide support in cases where there is an overlap with Care Act / MCA advocacy; b. services are commissioned on the basis of existing quality standards; c. providers are required …
Health & Social Care
Accepted
PHSO casework decisions(631)
P-001244 — A medical practice in the Manchester area
Mr E complained a medical practice mishandled his complaint, providing only one response in six months and failing to follow its own complaints procedure.
NHS in England
Upheld
Aug 2021
P-001151 — A medical practice in the Croydon area
Mr A complained the Practice incorrectly denied him priority COVID-19 vaccination, a locum doctor hung up on him, and his complaint response was unprofessional.
NHS in England
Oct 2021
P-001380 — A medical practice in the Derbyshire area
Mr I complained the Practice was abusive about mask-wearing, refused blood tests, removed him from its list, and mishandled his complaint, causing distress.
NHS in England
Apr 2022
P-001439 — NHS Surrey Heartlands
Ms R complained the ICB mishandled her complaints, including failing to acknowledge, reply to her MP, provide equality forms, and independently investigate, as well as providing a false explanation for cancelling a meeting.
NHS in England
Jun 2022
P-003196 — Department for Education
Mr I complained the Department for Education failed to fully address issues regarding an appeal panel member interrupting him and incorrect advice from a clerk, and lacked detail in its outcome letter.
UK Government
Dec 2024
P-003210 — Information Commissioner's Office
Mr T complains the ICO failed to properly handle his data protection complaint and review its own case handling, causing him to lose faith and impacting his wellbeing.
UK Government
Dec 2024
P-003695 — HM Revenue and Customs
Mr N complained HMRC failed to ensure a debt collection agency effectively addressed his complaints after HMRC incorrectly assigned a non-existent debt, causing him stress.
UK Government
Jul 2025
P-002416 — NHS England
Mr I complained NHS England mishandled his dental complaint, not taking it seriously and delaying their response, causing him ongoing pain, stress, and anxiety.
NHS in England
Jan 2024
P-002517 — A practice in the Barnet area
Mr O complained the Practice failed to respond to his complaints between December 2022 and November 2023, causing stress, anxiety, low mood, and delaying his hernia surgery.
NHS in England
Partly Upheld
Mar 2024
P-002543 — Harrogate and District NHS Foundation Trust
Mr Y complained the Trust refused to investigate his complaint about a missed diagnosis of a balance disorder, causing him frustration and impacting his daily life.
NHS in England
Apr 2024
P-003126 — Leicester, Leicestershire and Rutland Integrated Care Board
Mr M complained about significant delays and poor communication from the ICB in responding to his mother's complaint.
NHS in England
Nov 2024
P-003106 — Black Country Integrated Care Board
The ICB allegedly wrongly decided not to fully assess Mrs N for continuing healthcare funding and failed to properly handle the subsequent complaint.
NHS in England
Upheld
Nov 2024
P-003324 — Greater Manchester Integrated Care Partnership
Dr G complained that Greater Manchester Integrated Care Partnership failed to acknowledge its failings in managing mental health services, did not withdraw an outdated report, and improperly investigated his complaints.
NHS in England
Feb 2025
P-004784 — A practice in the Oadby and Wigston area
Ms A complained the practice decided her mother should be nil by mouth without a proper assessment, and about the time taken and lack of communication in complaint handling.
NHS in England
Upheld
Feb 2026
P-004785 — A practice in the Torbay area
Mr A complained the practice incorrectly completed his father’s death certificate, didn't provide an amended certificate without cost, and mishandled his complaint.
NHS in England
Feb 2026
P-004694 — Torbay and South Devon NHS Foundation Trust
Mr N complained the Trust had not fully addressed his questions regarding his wife's patient safety review, specifically about the involvement of her GP and haematologist.
NHS in England
Jan 2026
P-004697 — Oxford Health NHS Foundation Trust
Ms O complained about the conduct of the mental health crisis team and the Trust's refusal to formally investigate her complaints, which exacerbated her mental health issues.
NHS in England
Jan 2026
P-001193 — A medical practice in the Milton Keynes area
Ms R complained her father’s medical practice inadequately handled her complaint regarding district nurses using incorrect catheters, breaching confidentiality, and not acting with candour.
NHS in England
Upheld
Jun 2021
P-001141 — A medical practice in the Tameside area
Mrs E complained the practice falsely classified her letters as complaints, unfairly removed her and her husband from its list without warning, causing distress and difficulty finding a new GP.
NHS in England
Resolution
Oct 2021
P-001320 — Barts Health NHS Trust
Ms U complained about inadequate care for a skin condition, unnecessary antidepressant prescription, and significant delays by Barts Health NHS Trust in handling her complaint.
NHS in England
Mar 2022
P-001438 — University Hospitals Coventry and Warwickshire NHS Trust
Mr A complained about Mrs O's care, citing inappropriate ibuprofen use, delayed histology results, premature stopping of antibiotics, untreated infection, and inappropriate surgery. He also complained about the Trust's complaint handling.
NHS in England
Upheld
Jun 2022
P-001199 — Children and Family Court Advisory and Support Service
Mr E complained Cafcass failed to send him a safeguarding letter, that the letter contained misleading information, an FCA made prejudicial statements, and Cafcass's complaint responses were inadequate or delayed.
UK Government
Nov 2021
P-001317 — Independent Assessment Services
Mr H complained IAS failed to provide CCTV footage of his PIP assessment. This prevented him from disproving incorrect mobility information in the report, leading to financial loss and losing his Motability car.
UK Government
Nov 2021
P-001473 — HM Revenue & Customs
Mr A complained HMRC's debt recovery for a PAYE underpayment was unnecessary and poorly managed, causing distress during a difficult family time. He also criticized HMRC's complaint handling.
UK Government
Not Upheld
Jul 2022
P-001703 — Information Commissioner
Mr O complained the Information Commissioner's Office (ICO) failed to respond to his concerns and subsequent complaints within its own agreed timescales.
UK Government
Jan 2023
P-002692 — Information Commissioner's Office
The ICO took too long to issue a decision notice on an FOI request, preventing Mr M from performing his public watchdog function as an investigative reporter.
UK Government
Jun 2024
P-003351 — Office of Qualifications and Examinations Regulation (Ofqual)
Mrs P complained Ofqual refused to carry out an internal review of its decision, despite her submitting further evidence, causing her considerable upset, distress, and frustration.
UK Government
Feb 2025
P-003993 — Child Maintenance Service (CMS)
Mr R complained the CMS failed to carry out a mandatory reconsideration and asset valuation, did not provide callbacks, gave incorrect information, and failed to investigate income concerns since 2018.
UK Government
Sep 2025
P-004171 — Independent Case Examiner
Mrs A complained the Independent Case Examiner refused her DWP complaint as out of time, despite her receiving DWP's final response 17 months late.
UK Government
Oct 2025
P-001727 — Frimley Health NHS Foundation Trust
Mrs L complained Frimley Health NHS Foundation Trust delayed her husband's cancer diagnosis, provided inadequate palliative care, and mishandled her subsequent complaint.
NHS in England
Upheld
Jan 2023
P-002267 — Liverpool Heart and Chest Hospital NHS Foundation Trust
A patient complained the Trust made unkind comments about her deceased mother and a poem she wrote, and sent an insensitive letter after her mother's death.
NHS in England
Oct 2023
P-003047 — Cornwall Partnership NHS Foundation Trust
The Trust failed to provide him with an Emotional Coping Skills Course despite referral and improperly managed his complaint, changing the outcome without explanation, impacting his mental health.
NHS in England
Upheld
Sep 2024
P-003142 — NHS Resolution
Mr B complained NHS Resolution left questions unanswered, refused to provide an expert report copy, and bullied him during a complaint process about an NHS Trust.
NHS in England
Nov 2024
P-003482 — University Hospitals of Leicester NHS Trust
Mrs O complained the Trust failed to provide evidence of implemented procedural changes, updates, and options for her family, as promised in its previous complaint response.
NHS in England
Apr 2025
P-003728 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Mrs O complained the Trust mishandled her complaint by delaying responses, not conducting an independent investigation, failing to address all points, and withdrawing her care.
NHS in England
Partly Upheld
Jul 2025
P-003799 — A dental practice in the Mid Suffolk area
Mrs K complained about an ill-fitted temporary denture, cancelled appointments, and being unfairly barred from the practice after raising her concerns.
NHS in England
Upheld
Aug 2025
P-004286 — NHS England - South (South East)
Complaint concerned NHS England's failure to disclose a 'next steps letter' for his mother's continuing healthcare claim, preventing a full review and causing financial detriment.
NHS in England
Nov 2025
P-004392 — A practice in the Mansfield area
Mr R complained the Surgery dismissed his symptoms, provided inappropriate guidance, gave incorrect information about weight-loss injections, and poorly handled his complaint.
NHS in England
Dec 2025
P-004414 — University College London Hospitals NHS Foundation Trust
A patient complained the urology team did not address her reoccurring infection and she was wrongly discharged after receiving an unexplained behaviour warning.
NHS in England
Dec 2025
P-004529 — Croydon Health Services NHS Trust
Ms N complained about a locum's failure to examine her and provide correct information, poor appointment handling, and the Trust's inadequate complaint resolution.
NHS in England
Dec 2025
P-004772 — University Hospitals Coventry and Warwickshire NHS Trust
Mr A complained the Trust gave contradictory information about his father's treatment, failed to keep records, refused a statement, and delayed his complaint.
NHS in England
Feb 2026
P-004761 — HM Revenue and Customs
Mr D complained HMRC erroneously set his tax rate and estimated income, causing a large income tax underpayment, financial hardship, and unfair interest charges.
UK Government
Jan 2026
P-004763 — HM Revenue and Customs
Mr N complained HMRC did not correctly apply its Admin Law Manual (ADML1300) to his case, resulting in financial hardship from an underpayment claim.
UK Government
Jan 2026
P-004660 — Office for Standards in Education, Children's Services and …
Mr E complained Ofsted and DfE delayed investigating his safeguarding concerns about a school and failed to escalate them appropriately, causing him trauma.
UK Government
Jan 2026
P-004664 — Children and Family Court Advisory and Support Service …
Mr S complained a Section 7 report author was biased and Cafcass failed to replace the Family Court Adviser, despite concerns, causing distress and financial loss.
UK Government
Jan 2026
P-004679 — Health and Safety Executive
Mr N complained the HSE wrongly rejected his complaint about an inspector and the BSR failed to address his concerns. He also criticised the HSE's handling of his complaints.
UK Government
Jan 2026
P-004681 — Teaching Regulation Agency
Mr H complained the TRA took too long (over 5 years) to conduct a disciplinary hearing and notify him about an Interim Prohibition Order, causing significant financial and emotional hardship.
UK Government
Jan 2026
P-004691 — Leeds Teaching Hospitals NHS Trust
Mr A complained the Trust sent unexpected documents in a subject access request, including a cancer diagnosis he wasn't aware of, and incorrectly removed him from a knee replacement waiting list.
NHS in England
Jan 2026
P-004650 — Consumer Council for Water (CCW)
The Consumer Council for Water (CCW) failed to thoroughly investigate his complaint about a Water Company regarding a burst pipe, wrongly deeming it a private matter.
UK Government
Jan 2026
P-004655 — HM Revenue and Customs
HMRC failed to properly respond to his requests for information regarding alleged tax credit overpayments, leading to debt collection threats and stress.
UK Government
Jan 2026
LGO / SPSO decisions(8842)
24-021-176 — Nottinghamshire County Council
Summary: Mrs X complained the Council did not properly decide whether to prosecute a trader she complained about. We found the Council was at fault as it did not keep records showing how it decided not to prosecute the trader. To remedy the injustice caused the Council agreed to apologise …
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2025
201304283 — A Medical Practice in the Greater Glasgow and …
Ms C, who is an advice worker, complained to the medical practice on behalf of her client (Mr A) about his care and treatment. Ms C said she wrote to the practice several times, and phoned them, but they did not reply. Because of that, Ms C complained to us …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2014
201406475 — Commissioner for Ethical Standards in Public Life in …
Mr C had complained to a local authority about their services. When they did not investigate his complaint he asked a councillor to review the matter. The councillor felt that this would go beyond his remit and declined to become involved. Mr C complained about the councillor to the Commissioner …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Feb 2016
201404550 — Scottish Qualifications Authority
Mr C's daughter appealed to the Scottish Qualifications Authority (SQA) about her results in two subjects. Her appeals were not upheld. Mr C complained on behalf of his daughter to the SQA about the procedures they had followed and that they had not examined apparent administrative errors in the recording …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Mar 2016
201506127 — Crown Office and Procurator Fiscal Service
Mr C complained about a number of actions of the Crown Office and Procurator Fiscal Service (COPFS). Most were beyond our jurisdiction but Mr C also complained about how COPFS had responded to his complaint. We considered that, in their response, COPFS had addressed the issues Mr C complained of, …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
May 2016
201806670 — The Water Industry Commission for Scotland
Mr C complained that the Water Industry Commission for Scotland (WICS) failed to take reasonable or appropriate action in respect of the concerns he raised about a water provider. We found that WICS did not handle Mr C's concerns in line with their Policy for Licence Contraventions. We considered that …
SPSO (Scottish Public Se…
Water
Upheld
Mar 2020
25-007-696 — London Borough of Camden
Summary: We upheld Miss X’s complaint about delays in the children’s statutory complaints process. The Council agreed to resolve the complaint early by paying Miss X a symbolic remedy to recognise her injustice and complete its investigation.
LGO (Local Government & …
Children S Care Services
Upheld
Dec 2025
21-005-954 — Lancashire County Council
Summary: Ms X complained about the actions of the Council and the Enforcement Agency after she received a penalty charge notice. The Council was at fault when it and the Enforcement Agency failed to inform Ms X of her appeal rights or how to escalate her complaint. The Council has …
LGO (Local Government & …
Transport And Highways
Upheld
Jan 2022
21-004-999 — Bristol City Council
Summary: The Ombudsman found fault by the Council on Mrs Q’s complaint of it failing to act against a neighbouring allotment tenant after upholding her complaint and failing to respond to her correspondence. It failed to keep proper records, could not show it did what it said it would do, …
LGO (Local Government & …
Other Categories
Upheld
Feb 2022
21-014-433 — London Borough of Lewisham
Summary: The Council failed to provide evidence of compliance with a remedy it previously agreed with the Ombudsman. In the original complaint, we found the Council failed to investigate Mr B’s complaint The Council agreed to make a financial payment to recognise the impact of its fault. The Council was …
LGO (Local Government & …
Housing
Upheld
Feb 2022
21-009-815 — Tameside Metropolitan Borough Council
Summary: Mrs Y complains about the conduct of the Council’s presenting officer before a school admission appeal hearing. She complains the Council failed to respond to her complaint. We have upheld Mrs Y’s complaint that the Council has failed to respond to her complaint. This caused Mrs Y uncertainty. To …
LGO (Local Government & …
Education
Upheld
Mar 2022
21-004-840 — London Borough of Waltham Forest
Summary: Mr X complained he was excluded from the Council’s Rapid Employment Service. He also complained the Council’s investigation of his complaint was flawed. The Ombudsman found no evidence the Council excluded Mr X from its service. The Ombudsman did find fault in the Council’s record keeping and in the …
LGO (Local Government & …
Other Categories
Upheld
Apr 2022
21-013-440 — Bristol City Council
Summary: Miss X complains the Council failed to make a formal record of, or disclose, its reasons for refusing some applications for Community Infrastructure Levy and Section 106 funds. We have found fault with the Council’s actions. The Council has agreed to apologise to Miss X and make changes to …
LGO (Local Government & …
Other Categories
Upheld
Apr 2022
21-000-037 — Sheffield City Council
Summary: The Ombudsman found fault by the Council on Ms J’s complaint about its failure to take enforcement action against noisy neighbours. It failed to provide us with complete records, show it considered and reached a decision on her acoustic report, and failed to show whether officers properly considered and …
LGO (Local Government & …
Environment And Regulation
Upheld
Apr 2022
21-001-564 — London Borough of Haringey
Summary: Ms B complained about the delay in dealing with her complaint about children’s services. We found the Council delayed in completing the process and has not yet sent Ms B the reports in an accessible format. We have asked the Council to pay her £150 and send her the …
LGO (Local Government & …
Children S Care Services
Upheld
May 2022
21-008-100 — North Western Inshore Fisheries & Conservation Authority
Summary: Mr B says the Authority’s decision to prosecute his company was flawed at the outset; we find no fault in that action. We find the Authority failed to acknowledge Mr B’s correspondence, and it could have responded and managed Mr B’s expectations at that stage, which might have avoided …
LGO (Local Government & …
Other Categories
Upheld
Jun 2022
22-001-554 — Wigan Metropolitan Borough Council
Summary: The Council was at fault when it did not consider Mrs X’s complaints under the statutory children’s complaints procedures. The Council also delayed or failed to provide a substantive response to many of Mrs X’s complaints. It has agreed to apologise, pay her £250 and make service improvements to …
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
21-006-247 — Bolton Metropolitan Borough Council
Summary: Mr X complains that the Council did not tell Mr P that his direct payment account was in arrears, and arrears were building up over years. Mr X says this caused Mr P unnecessary distress. We find the Council at fault, and this fault caused Mr P and Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-002-492 — London Borough of Haringey
Summary: We will not investigate this complaint about the Council’s complaints team failing to respond to the complainant’s request for information. This is because the Council’s complaints team has now apologised for its failure to respond but confirmed another team did respond to the complainant’s concerns. So, there is nothing …
LGO (Local Government & …
Environment And Regulation
Aug 2022
22-003-365 — Worcestershire County Council
Summary: Mrs X complained the Council delayed considering her complaint at stage three of the children’s statutory complaints procedure. She says the delay has caused frustration and distress. The Council was at fault when it did not hold the stage three panel within the statutory timescales. The Council has agreed …
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2022
21-013-725 — Warrington Council
Summary: We found fault on Mr J’s complaint about how the Council responded to his reports of his property flooding and to his formal complaint. The Council communicated poorly with him but took steps to improve communication in the future. The Council failed to keep proper records. The agreed action …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-006-804 — East Riding of Yorkshire Council
Summary: We have upheld this complaint because the Council delayed consideration of a complaint at stage two of the children’s statutory complaints procedure The Council has now agreed to resolve the complaint by providing an appropriate remedy for the injustice caused to the complainant by its delay.
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2022
22-000-208 — London Borough of Camden
Summary: Miss X complains the Council unfairly placed her on its Unreasonable Complainant Behaviour register. Although we have not seen any evidence of fault in the Council’s decision to place Miss X on the register, we cannot see that it considered an appeal from Miss X in line with its …
LGO (Local Government & …
Other Categories
Upheld
Sep 2022
21-011-711d — CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-711c — Woking and Sam Beare Hospice and Wellbeing Care …
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
22-000-253 — East Riding of Yorkshire Council
Summary: Miss B complained about excessive delay by the Council in completing the statutory complaints process and its failure to implement the agreed recommendations. We found fault in the Council’s failure to implement the recommendations in full and its poor communication with Miss B in respect of these actions. The …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
22-008-036 — Reading Borough Council
Summary: We uphold Ms X’s complaint that the Council failed to consider his complaint within its children statutory complaints’ procedure. The Council has agreed to do so without further delay.
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
21-018-132 — Surrey County Council
Summary: Mrs X complains the Council has not completed some of the agreed remedy actions after it upheld her complaints following an investigation under the children’s statutory complaints procedure. The Council is at fault. It has not completed some of the actions agreed. There was also poor record keeping which …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
21-017-125 — Surrey County Council
Summary: Mrs X complained that the Council failed to deal properly with her complaint under the three-stage children's social care complaints procedure. The complaint was about failure to respond adequately to her requests for extra social care support for her disabled son. The children’s social care complaint investigation identified failings …
LGO (Local Government & …
Children S Care Services
Not Upheld
Oct 2022
22-005-982 — Leeds City Council
Summary: Miss B complained about the Council’s action in respect of council tax involving her business. She said the Council delayed in responding, then gave her incorrect advice, proceeded with recovery action even though she had made a complaint and delayed in responding to her complaint. We found fault with …
LGO (Local Government & …
Benefits And Tax
Upheld
Nov 2022
22-000-598 — London Borough of Havering
Summary: Ms J complained the Council caused delays in deciding her housing register application and failed to respond to her complaint as set out in its policy. She also said its housing service officers customer service was poor. We found the Council’s customer service was poor, and there were delays …
LGO (Local Government & …
Housing
Upheld
Dec 2022
23-015-707 — Coventry City Council
Summary: We have upheld this complaint about delay in the children’s statutory complaints procedure. This is because the Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused.
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2024
24-008-972 — Bolton Metropolitan Borough Council
Summary: Mrs K complained the Council did not cut the grass in a cemetery, causing it to become overgrown and inaccessible. She also complains the Council did not respond to her complaint about this. We consider the fact the Council did not cut the grass to be service failure, and …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
24-004-402 — Woking Borough Council
Summary: Mr X complained the Council unfairly rejected his application to hold a circus on its land and poor complaint handling. We found the Council was at fault because it did not respond to his complaint or several enquiries by us. This caused Mr X avoidable distress, time and trouble. …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
24-011-008 — Newcastle upon Tyne City Council
Summary: Mr X complained about how the Council delivered support to his son. We have found that the Council was at fault, because it has not yet dealt with Mr X’s complaint properly. It will now do so. It has also agreed to make a symbolic payment to Mr X …
LGO (Local Government & …
Children S Care Services
Upheld
May 2025
25-002-083 — London Borough of Lewisham
Summary: Miss X complained the Council failed to deliver services to her child. She also complained about its complaint handling. We found the Council was at fault. Miss X did not have the opportunity to have her complaint properly considered via the children’s statutory complaints procedure. The Council will apologise …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2025
24-022-089 — South Tyneside Metropolitan Borough Council
Summary: We uphold this complaint that the Council used another process rather than the statutory procedure for complaints about children’s services to respond to Mrs X’s complaint. The Council has agreed to resolve the matter by providing a suitable remedy for the injustice caused to Mrs X.
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-016-941 — Bury Metropolitan Borough Council
Summary: Mr B complained the Council has repeatedly left his bins blocking access to his driveway after collections, despite assuring him this would be resolved. The Council was at fault. It continued to leave Mr B’s bins blocking his driveway, after agreeing to leave them elsewhere. It also demonstrated poor …
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2025
24-012-224 — Thanet District Council
Summary: Mrs B complained the Council failed to adequately investigate her complaint of an officer’s conflict of interest. We find the Council at fault for a delay in completing its investigation and failing to keep investigation records. This has caused Mrs B frustration, distress and uncertainty. The council has agreed …
LGO (Local Government & …
Planning
Upheld
Aug 2025
24-020-123 — Milton Keynes Council
Summary: We have upheld Miss X’s complaint because the Council delayed responding to her complaint and considered the complaint under the incorrect procedure. The Council has agreed to provide a proportionate remedy to Miss X.
LGO (Local Government & …
Children S Care Services
Upheld
Sep 2025
201003128 — Glasgow City Council
Mr C and Ms D were involved in extra-curricular activities at their son’s school. They were uncomfortable with the actions of another parent, who they felt was promoting unacceptable racist and sexist views among the school community. Ms D, in particular, felt the parent was using bullying behaviours to make …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2011
201002957 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C suffers from Graves or Thyroid Eye Disease which is a complex and devastating condition. She complained that after 2007 her care and treatment was poor and likened it to a ‘production line’. She alleged that she had been examined and discharged without comment from either medical or nursing …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2011
201100439 — Scottish Prison Service
Mr C, who is a prisoner, complained following a decision taken by the prison to refuse certain items of property he requested to have in use. Mr C said the decision taken by the prison was unreasonable and he said his request had not been considered in line with the …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Nov 2011
201103592 — Grampian NHS Board
Ms C was injured when there was an accident involving the stair lift on which she was being transported by a member of the Scottish Ambulance Service (the Service) to a hospital appointment. She complained that, following the accident, she reported the matter to the receptionist at the clinic and …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2012
201200078 — Dumfries and Galloway Housing Partnership
Mr C, who is a councillor, wrote to the housing partnership on behalf of a tenant (Mr A) who was unhappy with their handling of his complaint about the way he was treated by a staff member. Mr C complained that he was given inaccurate information about the partnership's complaints …
SPSO (Scottish Public Se…
Local Government
Upheld
Sep 2012
201103657 — Fife Council
Mr and Mrs C complained about comments that they said a council officer had made about Mr C. The council initially dealt with the complaint through the statutory social work complaints procedure and upheld it. However, after taking legal advice the council decided that the complaint had been outwith the …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2012
201103632 — Perth and Kinross Council
Mr C acts as guardian and carer for his disabled adult son. He complained that the council did not properly investigate a complaint that he made on behalf of his son. He also said that they did not provide advice about the social work complaints procedure, by failing to tell …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2012
201202059 — Forth Valley NHS Board
Mr C, who is a prisoner, complained to the board about the medication decisions taken by his prison health centre. Mr C was not satisfied with their reply, which he felt had not addressed his concerns, and so he sent them a follow-up letter. However, the board sent it back …
SPSO (Scottish Public Se…
Health
Nov 2012
201103742 — Tayside NHS Board
Ms C complained about the care and treatment she received from a hospital. She outlined eight specific areas of concern, including communication, standard of care, waiting times, lack of after care and competence of staff. She said that she initially went to the hospital with symptoms of bowel disease, but …
SPSO (Scottish Public Se…
Health
Not Upheld
Nov 2012
201103618 — Fife Council
Mr C raised a complaint about the council's handling of a cement batching plant at a quarry. In particular, Mr C complained that the cement batching plant had changed from being an ancillary operation at the quarry to a mainstream operation and that the council had failed to require the …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2012
Domestic Homicide Reviews(267)— showing 50 strongest matches
Wokingham — recommendation R6
Review and improve record keeping systems in memory clinic to ensure that administration staff taking calls from patients record the call and identify a staff member to return the call in a timely manner.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Oxford — recommendation 3
Reducing the Risk should ensure improved record keeping in particular of work prior to MARAC referral and associated activation of the IDVA casework software.
Reducing the Risk of Domestic Violence
South Tyneside — recommendation AP17
The Role of the Duty Supervisor: All supervisors for officers and staff responding to and investigating domestic abuse are to be reminded that it is the duty of the front line supervisor to ensure that the DASH form and domestic abuse screens are fully completed before the officer terminates their …
Northumbria Police
Northumbria Police
South Tyneside — recommendation AP16
All incidents of Domestic Abuse to be recorded accurately with a DASH risk identification checklist.
Northumbria Police
Northumbria Police
South Tyneside — recommendation AP12
Case supervision to be held on file. Verbal discussions of cases and recommendations from management should be recorded within the contact notes of the file to evidence management oversight.
South Tyneside Council – Early Years’ …
South Tyneside — recommendation AP10
Review the systems for recording information, advice calls and referrals
South Tyneside Council – Early Years’ …
South Tyneside — recommendation 18.2.5
This is a list of domestic abuse records which Officers have failed to complete. Incomplete records should be completed as soon as possible to avoid further delay in the risk assessment process. The Duty Supervisor is intrusive of reports of domestic violence and abuse to ensure ‘all reports of domestic …
Northumbria Police
Northumbria Police
South Tyneside — recommendation 18.2.5
All supervisors for Officers and staff responding to and investigating domestic abuse are to be reminded that it is the duty of the front line supervisor to ensure that the DASH form and domestic abuse screens are fully completed before the Officer terminates their duty, this includes completion of the …
Northumbria Police
Northumbria Police
South Tyneside — recommendation 18.2.3
Case supervision should be held on file. Verbal discussions of cases and recommendations from management should be recorded within the contact notes of the file to evidence management oversight.
South Tyneside Council: Early Years Service
South Tyneside — recommendation 18.2.3
Early Help and Advice Teams to review their systems for recording information and advice calls and referrals as appropriate.
South Tyneside Council: Early Years Service
Lancaster — recommendation 15
Have chronology sheets on hand to record any concerns that maybe disclosed by anyone.
Nursery Two
Lancaster — recommendation 12.
Clinicians‘ practice of routine enquiry needs to be evidenced and incorporated into the standard EMIS templates
East Lancashire Clinical Commissioning Group
Sefton — recommendation 14
Clinical Record Keeping must be adhered too – clinical records must reflect the episode of care- RM 06 Policy for the Reporting and Management of Incidents-
Southport and Ormskirk Hospitals NHS Trust
Sefton — recommendation 12
Clinical Record Keeping must be adhered too – clinical records must reflect the episode of care
Southport and Ormskirk Hospitals NHS Trust
Haringey — recommendation 1
That the CPS review and revise its record-keeping policy so that it can contribute meaningfully to Domestic Homicide Reviews by providing details of its decision-making in cases of domestic abuse and where protective orders are in place.
Crown Prosecution Service
Crown Prosecution Service
Chiltern — recommendation WWA Recommendation 2
The IDVA Manager to ensure that notes are taken and kept of all group case management meetings.
Manager Wycombe Women’s Aid
Chiltern — recommendation BCC Recommendation 1
Parenting assessments on adults resulting in significant findings should be recorded and accessible when relevant.
Children Social Care
Chiltern — recommendation SMART Recommendation
A review of record keeping practices should be undertaken across the organisation to ensure consistent quality of case notes and record storage. This is to be initially undertaken via local case notes file audits
SMART– Service Manager
Chiltern — recommendation TVP Recommendation 5
Thames Valley Police to ensure MARAC co-ordinators include a summary of MARAC discussions and actions in the Risk Management Occurrence.
D/Supt – Crime & PVPSU
Kingston upon Thames — recommendation 36
Where a subsequent referral is made to children’s services within 30 days of the previous referral, Helpline practitioners should seek an update on action taken and record the response on the case file.
NSPCC
Kent — recommendation 20.
KMDASG must establish a process that ensures all MARAC actions from the previous meeting have either been implemented or if not, the reasons why. A record must be kept of the results.
KMDASG
Kent — recommendation 19.
KMDASG should agree a process that ensures minutes are taken at all MARAC meetings and include this in the Kent and Medway MARAC Operating Protocol and Guidelines.
KMDASG
Leeds — recommendation WYP2
That West Yorkshire Police remind Safeguarding Unit staff of the importance of formally recording third party concerns that a victim is subject to abuse.
West Yorkshire Police
West Yorkshire Police
Leeds — recommendation LASCR3
The new recording system which will be used by Adult Social Care (CIS) to link recommendations identified within the AMHP assessment with evidence that actions have been completed.
Leeds Adult Social Care
Rochdale — recommendation 8
Better communications to be completed on VS case management system.
Victim Support
Middlesbrough — recommendation 3
Written Update and evidence provided to Middlesbrough Community Safety Partnership that a previous recommendation ‘an audit be conducted to ensure there is no evidence of ‘copy and pasting’ of entries in clinical records by Clozapine clinic staff’ has been adequately addressed.
Tees Esk and Wear Valleys NHS …
Tees, Esk and Wear …
Nottingham — recommendation Notts SVS 2
Notts SVS Services workers, when sending emails will consistently state the DPMS ID and Flag on all internal communications with a requirement for the worker receiving the email to acknowledge receipt of the email to the sender and to update the sender once an action has been completed. Notts SVS …
Nottingham Sexual Violence Support Service
Norfolk — recommendation 33
When a family member has raised concerns about a student’s wellbeing, notes of the information given by the family member and their concerns should be recorded, placed on the student’s file, and a summary of their concerns emailed to the family member to ensure the summary is an accurate representation …
University of Manchester
The University of Manchester
Cornwall — recommendation 7
CFT to introduce a policy requiring staff to document information about care and staff involvement at the time of an incident which is reported as a Serious Incident (SI).
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Cornwall — recommendation 4
Review of current RiO quality manual and risk management policy to ensure the information is clear and compatible. Establish clear standards for how to use the risk summary, including staff must record in each section, where there is no new information staff to record ‘no new information’.
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Cornwall — recommendation 3
CFT provide an easy to read aid memoire card to clinical staff outlining good practice and expected structure of writing progress notes. The aim is to improve the quality of the progress notes, for staff to consistently record information in a structured format that includes: date, time of contact, purpose …
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Cornwall — recommendation 2
CFT use the 'Human error model' to identify the cause of poor practice in record keeping in clinical records (slip/lapse, mistake, violation) and design a solution based on the findings.
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Cornwall — recommendation 1
CFT review the current performance data for dates / timescales of review, undertake an audit of records to consider overall standards of record keeping and quality of content. Develop an action plan as required.
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Gateshead — recommendation 3
Ministry of Defence to implement routine, meaningful and accessible recording of all domestic abuse allegations that are made against service personnel;
Ministry of Defence
Ministry of Defence
Lincoln — recommendation 10.5.4
To develop a formal 12 month schedule of random record keeping reviews for community district nursing staff to identify risk assessment record keeping skills.
Lincolnshire Community Health Service
Lincolnshire Community Health Service …
Lincoln — recommendation 10.4.8
Adult Care should ensure that measures are in place to improve and assure the consistency and quality of case recording. Also ensure that electronic recording consistently evidences that the key components of case history and hazards are shown in the record.
Lincolnshire County Council Adult Care
Croydon — recommendation AE
Significant conversations with parents to be recorded on the schools online ‘Class log book’. This will be passed up to each teacher to ensure that any concerns raised in previous years can be considered.
Primary School
Croydon — recommendation P
Undertake a recordkeeping audit 12 months after implementation of the FHNA to review and monitor success.
Croydon Health Services NHS Trust
Croydon Health Services NHS …
Croydon — recommendation J
Apply good recordkeeping standards by making records at the time the events happen, or as soon as possible afterwards
Croydon ICB
Croydon — recommendation I
Recordkeeping to capture follow-up discussions practitioners in primary care are having with other statutory partners and this could be incorporated in audit programme at GP practices
Croydon ICB
Leicester — recommendation North Northants Home
Ensure that staff are reminded of the importance of always adding contemporaneous and detailed notes of all customer interactions and enquiries / actions.
North Northants Homelessness
Kent — recommendation 11
Kent and Medway Domestic Abuse and Sexual Violence Group must agree a process that ensures all MARAC meetings are accurately minuted and that the allocation and implementation of actions are recorded. The agreed process should be included in the Kent and Medway MARAC Operating Protocol and Guidelines.
KM DASVG
Kent — recommendation 5
Centra must instruct their IDVAs to record the rationale for their decision whether to meet a victim face to face.
Centra
Somerset — recommendation 11
Reinforce the necessity to record contemporaneous notes at the scene of domestic abuse incidents and a referral is made to Trust Safeguarding Team within the 48-hour time scales which SWASFT policy requires.
South Western Ambulance Service NHS Foundation …
South Western Ambulance Service …
Somerset — recommendation 5
Improve consistency of community mental health staff always clearly documenting source of disclosure of historic domestic abuse relevant details, whether or not the information can be substantiated.
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Salford — recommendation 1
Salford CSP should seek assurance from its member organisations that they have procedures and governance in place to ensure that all contacts with service users are recorded and acted upon as necessary (i.e. if the service user is considered to be at risk). This should include assurance that professionals ask …
Salford CSP
Havering — recommendation 2
It is recommended that BOCU SLT debrief the attending officers involved in this investigation to remind them of the importance of documenting non crime DA CRIS investigations and to complete ACN Merlin reports for each individual where vulnerability has been identified using VAF (vulnerable adult framework).
BOCU SLT
Havering — recommendation 1
It is recommended that BOCU SLT dip sample ACN Merlin reports to ensure compliance in documenting reports for each individual where vulnerability has been identified using VAF (vulnerable adult framework) and re-inforce this by communicating this message to staff.
BOCU SLT
Nottingham — recommendation 20.7.2
The Men’s Service should identify how to improve timescales of referral checks and case notes.
Equation Men’s Domestic Abuse Service
Basildon
Investigation required into why the neighbourhood dispute was not recorded in front office/Northgate.
Family Mosaic
CJINI inspection reports(9)
The Handling of Complaints in the Criminal Justice System in Northern Ireland
Governance, The Criminal Justice System
Jul 2007
Police Service of Northern Ireland Customer Service Report
Policing, Police Internal Operations
May 2011
The handling of Complaints – A follow-up review of inspections recommendations
Governance, The Criminal Justice System
Apr 2014
Improving the Provision of Care for Victims and Witnesses within the Criminal Justice System Northern Ireland. A Follow-Up Review
Victims and Witnesses
Mar 2008
The Office of the Police Ombudsman for Northern Ireland – A process verification assessment
Policing, Police Ombudsman for Northern Ireland
Sep 2014
Telling Them Why – A Follow-Up Review of the inspection of the PPS giving of reasons for its decisions
Public Prosecution Service for Northern Ireland (PPS), Pros…
Oct 2015
A review into the methods the PSNI use to disclose information in respect of historic cases to the OPONI
Policing, Police Internal Operations, Police Ombudsman for …
Apr 2020
The care and treatment of victims and witnesses by the Criminal Justice System in Northern Ireland
Victims and Witnesses
Jul 2020
A Follow-Up Review of the care and treatment of victims and witnesses
Victims and Witnesses
Mar 2015