Delayed patient infection risk notification
Inconsistent guidance leading to delayed notification of patients about infection risks from surgery (e.g., Mycobacterium Chimaera).
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
7 inquiry recs
51 PFD reports
12 committee recs
2 HSSIB recs
13 CQC actions
7 PPO recs
6 IMB recs
1 Scottish FAI
48 PHSO decisions
16 LGO/SPSO decisions
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(7)
R41 — Laboratory specimen processing
Recommendation: Health Boards should ensure that there is no unnecessary delay in processing laboratory specimens, in reporting positive results and in commencing specific antibiotic treatment. Infection control staff should carry out regular audits to ensure that there are no unnecessary delays …
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
R37 — CDI senior assessment and treatment
Recommendation: Health Boards should ensure that any patient with suspected CDI receives full clinical assessment by senior medical staff, that specific antibiotic therapy for CDI is commenced timeously and that the response to antibiotics is monitored on at least a daily …
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
IBI-8a — Pre-1996 Transfusion Testing
Recommendation: When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.
Gov response: NHS England is committed to identifying all those infected with a bloodborne disease, however it is transmitted. We would like to reassure the public that evidence shows the likelihood of contracting Hepatitis C via a …
Accepted
R65 — Isolation for infectious diarrhoea
Recommendation: Health Boards should ensure that appropriate steps are taken to isolate patients with potentially infectious diarrhoea.
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
R63 — Effective CDI patient isolation
Recommendation: Health Boards should ensure that there is effective isolation of any patient who is suspected of suffering from CDI, and that failure to isolate is reported to senior 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
IR2-2 — Eligibility Conditions for Infected Persons
Recommendation: I recommend that the conditions of eligibility for admission of relevant infected persons to the scheme should be that: a) they have been diagnosed as being infected with one or more of HCV (including natural clearers who have suffered loss), …
Gov response: In accordance with recommendations 1 and 2 of the Second Interim Report, the Government is clear that both those who have been infected and affected by this scandal are eligible for compensation and is compensating …
Accepted
PENROSE-1 — HCV Testing for Pre-1991 Transfusion Recipients
Recommendation: The Scottish Government takes all reasonable steps to offer an HCV test to everyone in Scotland who had a blood transfusion before September 1991 and who has not been tested for HCV.
Gov response: Lord Penrose recommends that the Scottish Government should take all reasonable steps to offer a hepatitis C test to anybody who might have been infected before 1991 by a blood transfusion and who has not …
Accepted
Prevention of Future Deaths reports(51)— showing 50 strongest matches
Craig White
Concerns: The coroner noted concerns regarding protocols for pre-Infliximab tuberculosis screening, the awareness of healthcare professionals about TB risk, and the need for ongoing patient education. Additionally, prompt treatment initiation for suspected tuberculous meningitis was highlighted.
Overdue
Afifa Qaisar
Concerns: The coroner identified issues with inaccurate drug administration records, unavailability of resuscitation equipment, the patient not being notified to the RMO, delays in platelet transfusions, and a lack of fluid balance charting.
Overdue
Robert Jones
Concerns: The coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Response: • The Health Board stated it would ensure CT scan results are made available promptly and routinely monitored. • The Radiology department will undertake sampling of scan-to-report times for emergency … (AI summary)
Responded
Jackson Chadd
Concerns: The coroner identified a lack of effective supervision for paediatricians, particularly during out-of-hours, and insufficient independent consultant assessment for paediatric admissions. Concerns also included the ineffective application of national guidelines for fever in children under one year and a failure to act on a parent's concerns.
Response (Frimley Park Hospital): • The Trust appointed a new Emergency Department Paediatric Consultant and established a consultant responsible for Paediatric A&E. • The Trust implemented a policy requiring junior doctors to notify a … (AI summary)
Response (Royal College of Paediatrics Child Health): • The Royal College of Paediatrics and Child Health (RCPCH) commenced a review of its 'Facing the Future' standards, specifically reconsidering the frequency of consultant review for admitted children. • … (AI summary)
Overdue
Shannon Gee
Concerns: The coroner identified delays in resolving clinical disputes between organisations due to differing treatment thresholds, which created a gap in service provision. Difficulties with the transfer of medical notes and records were also noted.
Overdue
George Taylor
Concerns: The coroner noted the undesirable practice of sending 8 to 12 psychiatric patients out of county monthly due to a lack of acute beds, identifying a risk that this could lead to a future death.
Response (Department of Health): • The Minister made NHS England aware of the report. (AI summary)
Response (NHS Kernow Clinical Commissioning Group): • NHS Kernow commissions 54 acute mental health assessment and treatment beds and has a contract with Cygnet Hospitals for additional specialist beds. • It is working with partners to … (AI summary)
Responded
Mary Marshall
Concerns: The coroner identified a lack of awareness among healthcare practitioners, especially General Practitioners, regarding the significance of GDH positive results for Clostridium Difficile risk and future antibiotic prescriptions. Concerns were also raised about the absence of consistent procedures in hospitals nationwide for communicating these results to primary care providers.
Response (Department of Health1): • NHS England's Antimicrobial Resistance work programme has promoted C. diff testing through national workshops and a study, making materials available online. • NHS England will work with partners to … (AI summary)
Responded
James Bateley
Concerns: The coroner noted concerns regarding the lack of ready access to essential pressure sore dressings for nursing homes and community nurses, as ordering through a GP could take up to 14 days.
Response (Coastal West Sussex Clinical Commissioning Group): • An investigation was conducted involving the Quality Assurance team, medicines management, safeguarding adults, the residential care home, and the GP surgery to examine delays in accessing dressings. • The … (AI summary)
Response (Sussex Community NHS Trust): • The Trust met with the Clinical Commissioning Group to discuss concerns regarding dressing provision. • A 'Stock box/First Dressing' system and an escalation process for delayed dressing supply were … (AI summary)
Responded
Sally Ellison
Concerns: The coroner noted a delay in sending a urine sample for legionella analysis despite early recognition of atypical pneumonia, which may have delayed optimal treatment. Concerns were also raised regarding the lack of a rapid testing and reporting service for legionella.
Response (NHS Wales): • Changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300. • The Pathology Clinical … (AI summary)
Responded
Alan Stead
Concerns: The coroner identified delays in taking and testing blood samples from prisoners at HMP Dovegate, asking what actions can be taken to improve this situation at the prison and potentially others.
Response (Care UK): • A phlebotomy training programme for all nurses and healthcare assistants was introduced at HMP Dovegate in December 2015. • The phlebotomy training programme was completed, and staff were deemed … (AI summary)
Responded
Gordon Arthur
Concerns: The coroner raised concerns about the absence of policies at the Trust regarding the process for ordering investigative tests and ensuring their results are communicated to the consultant in charge.
Response (Salford Royal NHS Trust): • A joint review of current trust policies for ordering and communicating radiological investigation results was carried out. • Existing protocols for rapid notification of unsuspected pathology and alerting clinicians … (AI summary)
Responded
Raymond Edwards
Concerns: The coroner noted a lack of a reliable system or protocol for disseminating histology results to the named consultant, especially after patient discharge. This could lead to delays in diagnosis and treatment of serious conditions.
Response: • The Health Board has begun work to develop the CHAI Ping app. • The app is intended to provide an electronic reporting system to alert requesting clinicians when histology … (AI summary)
Responded
Patricia Parker
Concerns: The coroner noted that guidelines relating to sedation use should be more widely disseminated to clinicians. NHS England should also highlight the problems of sedation, particularly in the elderly, and encourage local training for hospital staff.
Overdue
Tomas Kelly
Concerns: Concerns were raised regarding the inconsistent provision of information to parents of children with Down Syndrome about their increased infection risks, and the need to consider routine chickenpox vaccination for this group.
Response (Joint Committee on Vacccination and Immunisation): • The Joint Committee on Vaccination and Immunisation stated it would give consideration to the suggestion regarding Down’s syndrome during its ongoing review of varicella vaccination advice. (AI summary)
Responded
Edna Collett
Concerns: The coroner noted delays in discharging patients who were medically fit for discharge, specifically due to difficulties in securing suitable social placements, leading to prolonged hospital stays.
Overdue
Dylan Hill
Concerns: There are no formal procedures for health services to report non-fatal anaphylactic reactions caused by commercial food premises to regulatory bodies like Trading Standards. This lack of communication prevents timely intervention and appropriate action regarding allergen risks at such premises.
Response (Food Standards Agency): • The Food Standards Agency (FSA) provided stakeholders with messaging on allergen information and labelling rules and clarified enforcement in the Food Law Code of Practice and Practice Guidance. • … (AI summary)
Response (Barnsley Hospital NHS Trust): • The anaphylaxis draft protocol was reviewed and updated. • The revised protocol includes a referral form to inform Trading Standards of anaphylactic reactions linked to commercial food premises. • … (AI summary)
Response (Department of Health): • The Food Standards Agency (FSA) intends to establish cross-government discussions to consider the matter of reporting non-fatal anaphylaxis. • Barnsley and Sheffield are exploring the development of local notification … (AI summary)
Responded
Tom Cribley
Concerns: The coroner raised concerns about the lack of a systematic and monitored training programme for clinical staff in sepsis identification and treatment. This is crucial given recurring issues identified in documentation, timely escalation of patient deterioration, and handovers.
Overdue
Peter Knight
Concerns: The coroner noted delays in the completion and trial of a new policy for transferring oxygen-dependent patients, which was not finalised by the agreed deadline following the inquest.
Response (The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust): • The Transfer of Patients Policy was ratified at the Clinical Governance Committee meeting on 7th May. • The Trust stated it had visited the family to apologise for the … (AI summary)
Responded
Prabhaker Kapoor
Concerns: The coroner noted a delay in reviewing and updating safer swallowing training for staff, despite an earlier recommendation for completion by May 2019. The relevant training package had not been updated, and no new timeframe for completion could be provided.
Response (Birmingham Hospitals NHS Trust): • The content of the Moodle training package has been updated and will be available to staff by 21 October 2019. • A task and finish group was established to … (AI summary)
Responded
Peter Smith
Concerns: The coroner noted significant delays in the diagnosis and treatment of Mr Smith's adenocarcinoma. Tests and appointments occurred consecutively rather than concurrently and expeditiously, preventing surgery from taking place.
Response (Response from. UNMH): • A Standard Operating Procedure (SOP) for the referral for surgical resection of proven or suspected lung cancer was produced by Shrewsbury and Telford Hospital NHS Trust (SaTH) in conjunction … (AI summary)
Responded
Ibiyemi Ereoah
Concerns: Insufficient gynae-oncology consultant cover at Newham University Hospital hindered patient advocacy and oversight. The coroner also noted the absence of a system for timely consultant reviews, and that previously agreed actions to address these issues had not been completed.
Overdue
Brenda Elmer
Concerns: The coroner raised concerns about the lack of communication to out-of-area hospital patients regarding a Listeria outbreak, which delayed diagnosis. They also noted no legal requirement for private labs or hospitals to share Listeria isolates, impeding early outbreak identification.
Response (UK Health Security Agency): • PHE hosted a multi-agency lessons learned exercise following the outbreak. • PHE wrote to national microbiological standards, resulting in an updated Standard Operating Procedure advising hospital laboratories to refer … (AI summary)
Responded
Joan Sanderson
Concerns: The coroner noted the absence of a routine MRSA swab on hospital admission for certain patient groups, which delayed the early identification of infection. This practice could impact outcomes in cases requiring emergency surgery with postoperative infection.
Response (GM Health and Social Care Partnership and Healthcare Safety Investigation Branchwillbe): • The Greater Manchester Health and Social Care Partnership (GMHSCP) reported that the MRSA Policy was updated in February 2019 to align with national screening guidance for specific patient admissions. … (AI summary)
Overdue
Leslie Harris
Concerns: The coroner raised concerns regarding the interpretation of Public Health England guidance on patient movement to Covid-19 isolation wards, noting that varied interpretations across trusts could put vulnerable patients at risk of infection.
Response (NHS England): • The national IPC guidance was updated on 20 August 2020 to include examples for managing COVID-19 risks through specific pathways. • A further update to the guidance was published … (AI summary)
Response (UK Health Security Agency): • Public Health England (PHE) updated its guidance on managing staff and exposed patients, including on 4th April 2020 and 15th May 2020, to strengthen advice on isolation and cohorting. … (AI summary)
Responded
Norma Bradbury
Concerns: The coroner notes concerns regarding delays in GPs receiving discharge letters, deeming a three-day delay unacceptable when timely follow-up is required, as such delays risk impacting patient outcomes.
Overdue
Thiago Araujo
Concerns: The coroner noted Mr Araujo's crisis team referral was closed without addressing risks, and an unacceptable two-week delay occurred in securing a Mental Health Act assessment despite an identified acute suicide risk.
Response (St Pancras Hospital): • The Trust implemented new recommendations for discharge processes, including multi-disciplinary discussion and senior overview for non-engagement discharges, ensuring clear communication to carers and updated crisis plans. • The Trust … (AI summary)
Response (Royal Mail): • Royal Mail stated its existing processes for the handling of restricted and prohibited items within the mail system are adequate and appropriate. • Royal Mail stated it does not … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service updated its policies and procedures in May 2020 to assist staff with Mental Health Act warrants and requests from Approved Mental Health Professionals. • The … (AI summary)
Response (Dept. of Health and Social Care): • Officials brought the coroner's report to the attention of the Care Quality Commission (CQC). • The Department stated its commitment to expanding and transforming mental health services, supported by … (AI summary)
Response (Home Office): • The Home Office stated it is aiming to establish a consultation this summer on possible amendments to the Poisons Act, which will include more obligations on online marketplaces. • … (AI summary)
Overdue
Nicholas Winterton
Concerns: The coroner notes that Public Health England's nationally recognised risk for Mycobacterium Chimaera infection is inaccurate, based on outdated 2017 data and underreporting, impacting informed consent and timely diagnosis. An immediate review and update of this statistical data is required.
Response (UK Health Security Agency): • Public Health England (PHE) undertook an updated risk assessment in November 2019, which was submitted for publication but delayed, and will further update and publish risk estimates by September … (AI summary)
Overdue
Roger Phelps
Concerns: The coroner noted concerns about delays in COVID-19 swab results for inpatients, which led to asymptomatic infectious patients remaining on non-Covid wards and potentially spreading infection. It was unclear if this issue had been resolved by other trusts, meaning the risk might remain.
Overdue
Christopher Collinson
Concerns: The coroner noted that the patient allocation system required manual checks, meaning patients could be missed for assessment, and the electronic prescribing system lacked a secondary check for medication selection, risking incorrect medication administration.
Response (Queen Elizabeth Hospital): • The Trust implemented its in-house electronic system, PICS, at Birmingham Heartland’s Hospital (BHH) AMU in July 2021, which includes time markers to identify patients awaiting assessment. • The Trust … (AI summary)
Responded
Natasha Adams
Concerns: The coroner noted a patient's care level was downgraded without following trust policy, and an audit to check broader compliance with this policy had been significantly delayed.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): • An audit of compliance against the Care Programme Approach (CPA) was undertaken on 12 May 2022. • The audit results indicated that 80% of reviewed patients received a formal … (AI summary)
Responded
Trevor Reynolds
Concerns: The coroner noted delays in fully implementing a new Standard Operating Procedure for managing irregular scan reports and a lack of an audit process to ensure its effectiveness, which allows known risks to patients to continue.
Response (Betsi Cadwaladr University Health Board): • Clinicians and secretaries were made aware of the Standard Operating Procedure for urgent radiology results, and two audits of compliance were completed. • A new electronic solution for results … (AI summary)
Overdue
Angela Maguire
Concerns: The coroner highlighted the absence of a regional system for sharing radiology images between West London hospitals, which hinders image comparison and increases clinician workload, with potential for missed diagnoses and adverse patient outcomes.
Response (NHS England): • The NHS Long Term Plan committed to establishing Imaging Networks across England by 2023. • Twenty-two Imaging Networks are being supported to increase their maturity, with an aim to … (AI summary)
Overdue
Jack Hurn
Concerns: The coroner noted a lack of official Trust guidance on managing VITT, which led to delays in transferring the patient to a specialist centre and contacting appropriate consultants, despite national and regional guidance being available.
Response (NHS Worcestershire Acute Hospital): • The Trust reinstated the serious incident record entry and revised the investigation's terms of reference. • The Trust completed a gap analysis of national patient safety investigation standards against … (AI summary)
Responded
Rita Flynn
Concerns: The coroner noted that the patient was discharged from the hospital with indicators of infection before blood test results were available, which was contrary to best practice.
Response (The Royal Wolverhampton): • A section for investigations and results has been incorporated into the ED clerking document to ensure results are reviewed and documented prior to patient discharge. • An agreed plan … (AI summary)
Responded
Sara Jones
Concerns: The coroner identified an absence of a protocol for prompt and secure radiology report delivery. This meant a patient's CT scan report was delayed and unconfirmed after transfer, leading to doctors not following up on potential bowel injury signs.
Response (University Hospitals of North Midlands): • One additional major trauma consultant has been appointed, and negotiations are underway with three more to staff the Monday-Friday rota by August 2023. • A business case for expanding … (AI summary)
Response (Betsi Cadwaladr University Health Board): • A process has been established for sending radiology reports by email with telephone confirmation of safe receipt when a patient leaves an emergency department without a report. • This … (AI summary)
Responded
Akash Bhudia
Concerns: The coroner noted a lack of process to ensure significant, unexpected changes in follow-up X-rays, especially those highly suggestive of tuberculosis, are highlighted to referring clinicians in a timely manner for discharged patients.
Response (Medica Group): • Medica Group edited its Alerts policy to include potential new tuberculosis diagnoses as a reason for urgent notification to referrers. • The updated policy has been circulated to all … (AI summary)
Responded
Helen Coogan
Concerns: The coroner raised concerns that qFIT test results, requested for Ms Coogan in July and September 2022, were not received. The report identifies this as a matter for investigation to determine if there is a system issue.
Response (Ritchie Street Group Practice): • The practice discussed the case at a partners meeting. • A significant event was raised for discussion with the wider team. • The practice stated that no further learning … (AI summary)
Responded
Maria Shafighian
Concerns: The coroner noted concerns regarding the hospital's internal postal system for urgent notifications between teams, as there was no process to ensure urgent matters were brought to attention immediately or that mail was dealt with in a timely manner.
Response (Aneurin Bevan University Health Board): • The Health Board has agreed that internal referrals to the ENT department will be sent directly to the Central Registration department for electronic processing and triage. • The Head … (AI summary)
Responded
Clinton Fear
Concerns: The coroner raises concerns about the inconsistency between NHS guidance for notifying patients of Mycobacterium Chimaera infection risk (from January 2013) and evidence of infections occurring significantly earlier, which may lead to delayed diagnosis and harm for affected patients.
Overdue
Kai Takagi
Concerns: The coroner identified gaps in tracking and following up A&E patients with outstanding test results after discharge, noting reliance on un-auditable oral handovers and incomplete implementation of abnormal result reviews.
Response (NHS England): • NHS England published national guidance and standards for the communication of patient diagnostic test results on discharge from hospital. • NHS England published a two-year Delivery plan for recovering … (AI summary)
Overdue
Terence Hines
Concerns: The coroner identified the absence of a required "Red clean" for a room previously occupied by a patient with MRSA before Mr. Hines' transfer, alongside the omission of routine MRSA screenings that should have occurred during his prolonged inpatient stay and prior to surgery.
Response (Worcestershire Acute Hospitals): • The Trust updated its Red, Amber, Green (RAG) clean policy and guidance, including new posters and an updated Record of Terminal Cleans, to clarify requirements for MRSA patients. • … (AI summary)
Responded
Ethel Reed
Concerns: Inadequate staffing, leadership, and patient escalation pathways were identified on wards opened for winter pressures. The electronic patient system also fails to record the author of discharge letter changes, risking miscommunication and treatment delays.
Response (NHS England): • NHS England engaged with the Integrated Care Board regarding the concerns raised. • Hull Royal Infirmary made improvements to Ward H130, establishing a permanent team, and the Trust undertook … (AI summary)
Response (CQC): • The Trust permanently opened two wards (H130 East and H130 West) in June 2023 as part of a “Discharge to Assess” model, staffed by a multidisciplinary team, and established … (AI summary)
Response (Humber Health Partnership Hull Royal Infirmary): • The Trust established a permanent team and leadership structure on Ward H130, including daily Ward Sister presence and clear signposting, and developed a planned methodology for safely opening additional … (AI summary)
Overdue
David Curry
Concerns: The coroner noted a significant delay in Mr Curry's urgent surgery due to a lack of theatre capacity, which resulted in a prolonged stent dwell time and an increased risk of post-operative urinary infection and sepsis.
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England, which raised the concerns with the Norfolk and Waveney Integrated Care Board (ICB). • The Norfolk and Norwich University Hospital Orthopaedic Centre … (AI summary)
Responded
Gillian Stokes
Concerns: The coroner identified insufficient clinical guidance on radiation-induced sarcoma and first-line investigations for breast implant patients, noting the 5-year surveillance period is shorter than the condition's 10-year latency. There were also concerns that a hospital's 2-week post-aspiration review protocol was not followed.
Response (Department of Health and Social Care): • Officials will explore with the Medicines and Healthcare products Regulatory Agency and NHS England if more can be done to raise awareness of angiosarcoma following radiation with patients and … (AI summary)
Response (Royal College of Nursing): • The Royal College of Nursing (RCN) stated it is not a regulator and does not comment on individual cases. • The RCN indicated it was unable to comment on … (AI summary)
Response (Ashford and St Peters Hospitals NHS Foundation Trust): • The Trust reviewed the appointments process within the One Stop Shop breast clinic. • The Division is developing a Standard Operating Procedure (SOP) for the Breast One Stop Shop … (AI summary)
Response (Royal College of Radiologists): • The Royal College of Radiologists (RCR) confirmed that additional measures had been put in place to refine its process for responding to important correspondence. • The RCR has tasked … (AI summary)
Responded
Malcolm Taylor
Concerns: The coroner identified an insufficient number of mental health beds available at Norfolk and Suffolk NHS Trust to meet patient need, despite actions taken by the trust. This persistent shortage was also noted as a national problem.
Response (Department of Health and Social Care): • The Department stated it would continue to work with the NHS to address capacity across the mental health system. • NHS England's 2024/25 planning guidance directs local health systems … (AI summary)
Responded
Lee Armstrong
Concerns: The NHS Pathways system does not prompt for existing conditions, and information from 111 online is not shared with NWAS. Call handlers also lack access to patient medical records, which may lead to crucial medical history not being known during emergency calls.
Response (NHS England): • NHS England described the existing design of the NHS Pathways system, which is symptom-based and enquires about pre-existing conditions when they may alter assessment outcomes. • NHS England confirmed … (AI summary)
Response (Department of Health and Social Care): • The Department stated that NHS England has a process in place to map 999 call triage system outcomes against ambulance response time categories. • The Department noted that the … (AI summary)
Overdue
Khadija Kerri
Concerns: Doncaster Royal Infirmary has no clear internal policy for disseminating addendum reports or their information from external radiology services to the treating clinical team, risking delays and incorrect patient management.
Response (Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust): • The Trust reviewed its Failsafe Alert for Radiological Findings (Communication Protocol) and communicated with Everlight Radiology to agree on amendments. • The revised protocol is scheduled for approval and … (AI summary)
Responded
Gareth Tatchell
Concerns: The coroner noted delays in the diagnostic, staging, and treatment phases for suspected cancer, particularly regarding the time taken to complete staging scans. These ongoing delays are affecting survivability rates and prognoses.
Response (Bwrdd Lechyd Prifsgol Bae Abertawe): • The Health Board has implemented individual patient monitoring with weekly or fortnightly review meetings for cancer pathways. • Explicit targets for each stage of the cancer pathway are in … (AI summary)
Responded
Leslie Thompson
Concerns: The coroner noted that the lack of evening and weekend physiotherapy services in the hospital caused discharge delays, exposing patients who were medically fit but awaiting assessment to unnecessary risks in an acute hospital environment.
Response (Department of Health and Social Care): • The Department stated that every acute hospital has access to a care transfer hub, which is expected to operate seven days a week to minimise discharge delays. • The … (AI summary)
Responded
Nicola Mulliss
Concerns: The absence of a policy for microbiological wound swabs during re-suturing potentially delayed infection detection and treatment, which could have prevented fatal staphylococcal meningitis.
Response (Newcastle upon Tyne Hospitals NHS Foundation Trust): • The Trust will strengthen pathways for timely appropriate cultures, including wound swabs, when infection is suspected. • The Trust will ensure patients are commenced promptly on antibiotics where clinically … (AI summary)
Responded
Select committee recommendations(12)
#8 — Identifying and contacting all high-risk individuals after data breach remains difficult.
Recommendation: We asked the Department how it obtained assurance that those put at the highest risk from the data breach were identified and contacted.14 The Department told us that it undertook a risk assessment almost immediately after the breach was discovered, …
Response attribution not verified
#23 —
Recommendation: The Department told us that 429 asylum seekers had been tested for COVID-19, 122 of whom had tested positive.63 In its letter to us after our evidence session, the Department further explained that of those that had tested positive, 29 …
Response attribution not verified
#19 —
Recommendation: We asked the Department about specific examples where there had been issues with its engagement with local stakeholders. At the end of August 2020, the Department moved asylum seekers, 47 of whom had tested positive for COVID-19, from the Stone …
Response attribution not verified
#47 —
Recommendation: While Mears affirms that the dispersal of individuals from Urban House on 10 July without testing, even after cases of Covid-19 were confirmed in the facility, was in line with the national system, we are deeply concerned that the company …
Response attribution not verified
#46 —
Recommendation: We are extremely concerned at this failure of communication by Mears Group with the receiving local authorities, and at the lack of arrangements for testing individuals who were being moved across the country out of an accommodation centre where other …
Response attribution not verified
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Response attribution not verified
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Response attribution not verified
#45 —
Recommendation: The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the …
Response attribution not verified
#31 —
Recommendation: The resulting requirement to abandon testing people in the community during the critical early period of the pandemic cost many lives for a number of reasons including because: a) many asymptomatic carriers were not tested and therefore identified and asked …
Response attribution not verified
#16 —
Recommendation: As part of its new cancer plan, the Government should include a plan for how to better align the technology appraisals carried out by NICE with the regulatory process applied by the MHRA, in order to reduce the delay between …
Response attribution not verified
#15 —
Recommendation: For patients with limited treatment options the approval of a new drug or therapy can make a significant difference even when the survival benefit is only months. Despite the effectiveness of the Medicines and Healthcare products Regulatory Agency’s regulatory process, …
Response attribution not verified
#10 —
Recommendation: The vaccine programme still has some issues to address. In England, 2.98 million adults were still unvaccinated at the end of May 2022. Analysis by UKHSA has confirmed that full and booster vaccination reduces the risk of someone falling seriously …
Response attribution not verified
HSSIB safety recommendations(2)
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that NHSX develops a method of digitally notifying patients of results. This should be used to inform patients of unexpected significant radiological findings after an agreed timeframe. It should be developed in conjunction with the Royal College …
Safety Recommendation
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that the Royal College of Radiologists, working with the Society and College of Radiographers and other relevant specialties through the Academy of Royal Medical Colleges, develops: principles upon which findings should be reported as ‘unexpected significant’, ‘critical’ …
Safety Recommendation
CQC inspection actions(13)
William Harvey Hospital
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Must Do
Royal Lancaster Infirmary
The service should continue to monitor and review antimicrobial stewardship and prescribing in sepsis.
Should Do
Kidderminster Hospital and Treatment Centre
Ensure that all admission letters for elective patients ask them to highlight if they have been an inpatient in hospital within the last 12 months.
Should Do
Royal Lancaster Infirmary
The service must ensure women receiving maternity care, who are assessed as at risk of sepsis, have their care and treatment recorded in line with national guidance.
Must Do
Royal Lancaster Infirmary
The service must ensure women receiving maternity care, who are assessed as at risk of sepsis, have their care and treatment recorded in line with national guidance.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Must Do
Furness General Hospital
The service must ensure women receiving maternity care, who are assessed as at risk of sepsis, have their care and treatment recorded in line with national guidance.
Must Do
Furness General Hospital
The service must ensure women receiving maternity care, who are assessed as at risk of sepsis, have their care and treatment recorded in line with national guidance.
Must Do
Alde House
The registered persons failed to notify the Commission without delay of incidents which occurred whilst services were provided in the carrying on of the regulated activity, or as a consequence of the carrying on of the regulated activity. Such incidents …
Must Do
Alde House
The registered persons failed to notify the Commission without delay of the death of service users whilst services were being provided in the carrying on of the regulated activity.
Must Do
Suffolk House
The provider failed to ensure people were protected from the spread of infection and systems in place did not ensure risks were managed safely.
Must Do
Burrswood Health and Wellbeing
The registered provider must establish robust arrangements to ensure that a statutory notification is promptly submitted to the Care Quality Commission.
Must Do
Newland House
We recommend the registered manager and provider familiarise themselves with the circumstances when they need to make notifications to CQC by consulting the relevant regulations.
Should Do
PPO death in custody recommendations(7)
The Director and Head of Healthcare
The Director and Head of Healthcare should review the process in place for preparing applications for early release on compassionate grounds to ensure that the necessary evidence, including a specialist medical report, is obtained as quickly as possible.
The Head of Healthcare
ensure that the results of hospital investigations are promptly communicated to prisoners.
The Head of Healthcare
The Head of Healthcare should review the current vaccinations process to ensure that if a patient is unavailable, a further appointment is offered.
The Head of Healthcare at Stafford
The Head of Healthcare at Stafford should ensure that where prisoners are already under the care of a hospital consultant when they arrive, staff: • make hospital referrals promptly; • include all relevant information about the stage of treatment and …
The Head of Healthcare
The Head of Healthcare should ensure that prisoners returning to Bristol following a temporary absence are offered a medical review if they meet the criteria set out in PSI 07/2015.
The Head of Healthcare
ensuring requests for clinical investigations, such as requests for chest X-rays, are actioned promptly
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should work in conjunction with Royal Stoke University Hospital to ensure there is a robust and efficient system for receipt of histology and other laboratory results, and ensure that this information is promptly relayed to patients.
IMB individual recommendations(6)
Gartree (2021)
Will the Minister explain the reasons for the delay in rolling out booster Covid-19 vaccine in Gartree (albeit that the Board has been advised that vaccinations were rolled out as per PHE and NHSE guidelines except where prisoners were unable to have vaccinations because they had tested positive for Covid-19 within the previous 28 days)? It has been acknowledged that …
Ministry of Justice
Preston (2021)
Will the Minister review the current guidelines and ensure that all personnel within the prison are vaccinated irrespective of the guidelines for the general public (see section 3.1)?
Ministry of Justice
Rejected
Nottingham (2021)
The inability of the system to ensure that prisoners have a second vaccine appointment on release needs to be addressed (6.1).
HMPPS
Implemented
Tinsley House IRC (2020)
to reconsider its current policy of not Covid-19 testing detainees on arrival at Tinsley House STHF, or thereafter during their period of detention.
Home Office
Durham (2023)
What plans will be put in place to achieve an improved and sustained delivery of “secondary health screening within 7 days”? (6.2.3)
Governor / Director
Humber (2020)
The number of Patient Advice and Liaison Service (PALS) submissions which are not responded to within the stipulated 10 days is of concern to the Board. There was a total of 530 PALS submissions in 2020, 264 (50%) of which were not replied to within the specified timescale. Following a freedom of information (FOI) request, the healthcare provider - CHCP …
Governor / Director
Independent reviews(2)
Paterson Inquiry — Rec 8
We recommend that Spire should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the …
Health & Social Care
Paterson Inquiry — Rec 7
We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen.
Health & Social Care
PHSO casework decisions(48)
P-002750 — Maidstone and Tunbridge Wells NHS Trust
The Trust allegedly failed to monitor Mr R's infection and delayed antibiotic treatment for his cystic fibrosis, which negatively impacted his physical health.
NHS in England
Jul 2024
P-003770 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs C complained the Trust delayed giving her son, D, intravenous antibiotics for a UTI, leading to his rapid deterioration and death, believing this affected his survival chances.
NHS in England
Upheld
Aug 2025
P-001958 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr A complained his father contracted COVID-19 in hospital and later died, alleging the Trust failed to implement compulsory asymptomatic staff testing soon enough.
NHS in England
Not Upheld
Apr 2023
P-002002 — University Hospitals Birmingham NHS Foundation Trust
Mr Y complained his mother, Mrs Y, acquired a second infection as an inpatient and staff failed to inform him. He also criticised the Trust's complaint handling for not answering his questions.
NHS in England
May 2023
P-002553 — Stockport NHS Foundation Trust
Nurses failed to clean his wound after surgery, leading to severe infection, forcibly removed his surgical drain, and wrongly told him he had cancer.
NHS in England
Apr 2024
P-003085 — An independent provider in the Berkshire area
The Provider missed clear signs and symptoms of pneumonia, which led to sepsis, during a 111 call and an out-of-hours GP appointment for his son, who sadly died.
NHS in England
Oct 2024
P-003010 — Royal Devon University Healthcare NHS Foundation Trust
Mr E complained the cardiology team inappropriately discharged him, that he was exposed to flu in poor conditions, and the Trust failed to respond to his complaint, leading to a second stroke and financial strain.
NHS in England
Oct 2024
P-003418 — University College London Hospitals NHS Foundation Trust
Mr W complained his mother contracted COVID-19 on a ward, the Trust lacked communication, and failed to effectively treat her leg ulcer, leading to its deterioration and affecting her health.
NHS in England
Mar 2025
P-003454 — A practice in the Gloucestershire area
Ms G complained the Practice missed opportunities to diagnose and treat her ongoing infections between June 2021 and July 2023, causing her suffering and pain.
NHS in England
Mar 2025
P-003477 — A practice in the Wiltshire area
Mr O complained the Trust failed to identify rib fractures and provide antibiotics, leading to pain and a hip infection. He also complained about poor family communication and the Practice's delayed response to his injuries.
NHS in England
Apr 2025
P-003788 — Mid Yorkshire Teaching NHS Trust
Ms A complained her son was inappropriately catheterised, suffered delayed UTI/sepsis diagnosis and treatment, and received inadequate physiotherapy, leading to his death.
NHS in England
Not Upheld
Aug 2025
P-003768 — Portsmouth Hospitals University NHS Trust
Miss C complained the Trust didn't administer antibiotics before her baby's birth, despite her Strep B history, and ignored her concerns about jaundice before and after discharge.
NHS in England
Aug 2025
P-003785 — An independent provider in the Sheffield area
Miss H complained her condition deteriorated after surgery due to a haemorrhage requiring a second operation, and her wound became infected, prolonging recovery and impacting her mental health.
NHS in England
Aug 2025
P-004130 — A practice in the Oldham area
Mrs B complained the Trust failed to protect her sister from infection during investigations while she was undergoing chemotherapy, contributing to her chest infection and death.
NHS in England
Partly Upheld
Oct 2025
P-004401 — East Suffolk and North Essex NHS Foundation Trust
Mrs D alleged the Trust failed to test Mr D for flu, leading to a missed AHLE diagnosis and incorrect treatment, potentially shortening his life.
NHS in England
Partly Upheld
Dec 2025
P-001516 — The Royal Wolverhampton NHS Trust
Mrs I complained Trust staff failed to follow cross-infection guidelines, resulting in her father contracting and dying from COVID-19 in hospital.
NHS in England
Aug 2022
P-001695 — The Dudley Group NHS Foundation Trust
Miss I complained about incorrect medication, delayed antibiotics, not allowing a relative to attend tests, problems during a swallowing test, and failure to perform a post-mortem on her grandmother.
NHS in England
Nov 2022
P-001620 — University Hospitals of North Midlands NHS Trust
Mrs A complained about inappropriate medication, inappropriate administration of antibiotics, and delays in antibiotics for her mother's end-of-life care, causing a horrific death.
NHS in England
Nov 2022
P-001983 — Hampshire Hospitals NHS Foundation Trust
Ms C complained about poor communication, forced DNACPR, delayed physiotherapy, incorrect medical statements, abrupt treatment cessation, and inadequate documentation regarding her father's care.
NHS in England
May 2023
P-002439 — Mid and South Essex NHS Foundation Trust
Miss I complained the Trust failed to treat her mother's post-surgery infection, gave incorrect advice, and provided poor nursing care, which she believes caused her mother's death.
NHS in England
Feb 2024
P-002514 — Milton Keynes University Hospital NHS Foundation Trust
Ms C complained Trust staff delayed diagnosing and providing correct treatment for her father's COVID-19 illness in December 2020, which she believes led to his death.
NHS in England
Mar 2024
P-002565 — The Dudley Group NHS Foundation Trust
Care after a caesarean section led to an infection and sepsis, requiring further surgery and causing a diagnosis of PTSD.
NHS in England
Apr 2024
P-002652 — Stockport NHS Foundation Trust
Mrs O complained the Trust failed to notice her mother's deteriorating condition and COVID-19 symptoms, delayed testing, and unfairly restricted family visits during her mother's final hours.
NHS in England
May 2024
P-003445 — Warrington and Halton Hospitals NHS Foundation Trust
Ms R complained about lack of continuity of care during labour, failure to prevent infection, and delayed treatment, leading to her and her daughter contracting sepsis.
NHS in England
Mar 2025
P-003506 — West Hertfordshire Teaching Hospitals NHS Trust
Mrs P complained the Trust's heart procedure led to her mother's health deteriorating, she was discharged unfit, and an infection was unrecognised/untreated, causing sepsis and death.
NHS in England
Apr 2025
P-003638 — University Hospitals of North Midlands NHS Trust
Mr S complained the Trust discharged his immunocompromised wife without bone marrow results and later placed her on an unsuitable ward, leading to infection and her death.
NHS in England
Jul 2025
P-004083 — Barts Health NHS Trust
Ms C complained doctors at two Trust hospitals and GPs failed to diagnose her brother's stomach cancer and sepsis, leading to a late diagnosis and his death.
NHS in England
Sep 2025
P-004063 — Portsmouth Hospitals University NHS Trust
Mrs N complained the Trust failed to timely diagnose and treat her husband's colitis caused by C-DIFF, which she believes caused his death.
NHS in England
Sep 2025
P-004399 — East Suffolk and North Essex NHS Foundation Trust
A patient complained the Trust failed to detect abnormalities on his chest X-ray and delayed cardiology investigations, causing him distress.
NHS in England
Dec 2025
P-001113 — Northern Lincolnshire and Goole NHS Foundation Trust
Mrs L complained the Trust refused further treatment, including ventilation, for her COVID-19 positive daughter with learning difficulties, and a nurse sent her away from A&E.
NHS in England
Not Upheld
Sep 2021
P-001275 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs I alleged her mother caught COVID-19 in hospital due to poor ward placement, was discharged too late, transferred inappropriately, and enrolled in a trial without consent, leading to her death.
NHS in England
Partly Upheld
Jan 2022
P-001602 — University Hospitals Bristol and Weston NHS Foundation Trust
Miss A complained the Trust's poor dental treatment for her father, including not sedating him and prescribing fluoride instead of removing teeth, led to sepsis and his death.
NHS in England
Nov 2022
P-001981 — West Hertfordshire Hospitals NHS Trust
Mrs U complained her husband contracted COVID-19 at the Trust, leading to a heart attack and death. She also alleged poor hygiene care, resulting in thrush and no appropriate discharge medication.
NHS in England
May 2023
P-002051 — Barking, Havering and Redbridge University Hospitals NHS Trust
Ms A complained about delays in blood tests and a CT scan for her father, which she believes led to his cardiac arrest and death, causing her emotional distress.
NHS in England
Jun 2023
P-002966 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs F complained staff inappropriately discharged her mother without enough home oxygen, leading to a failed discharge, and gave false accounts of her mother's condition.
NHS in England
Sep 2024
P-003618 — St George's University Hospitals NHS Foundation Trust
Mrs Y complained St George's University Hospitals NHS Foundation Trust delayed identifying her husband's infected heel wound, leading to amputation, and discharged him without a catheter, contributing to kidney failure and his death.
NHS in England
Upheld
Jun 2025
P-003970 — Barts Health NHS Trust
Mr P complained the Trust failed to act on gallstone scans, provided an inappropriate ERCP by a trainee, and did not effectively treat infections, leading to his wife's early death.
NHS in England
Sep 2025
P-004178 — Dartford and Gravesham NHS Trust
Mrs A complained the Trust delayed allergy testing, blood tests, and scans for her child, miscommunicated sepsis, and mishandled feeding and specialist referrals.
NHS in England
Oct 2025
P-004259 — The Royal Wolverhampton NHS Trust
Miss N complained the Trust failed to inform her mother of a cancer diagnosis with family support, and did not provide adequate pain relief, causing distress and physical pain.
NHS in England
Upheld
Nov 2025
P-001319 — The Royal Wolverhampton NHS Trust
Patient's daughter alleged her father contracted COVID-19 in hospital, was inappropriately discharged, and was pressured into a Do Not Attempt Resuscitation decision.
NHS in England
Not Upheld
Feb 2022
P-001904 — Countess of Chester Hospital NHS Foundation Trust
A doctor allegedly pushed an IUD into Ms E's womb during a 2015 procedure, causing a severe infection and requiring surgery. The Trust also failed to respond to her complaint.
NHS in England
Mar 2023
P-002248 — University Hospitals Sussex NHS Foundation Trust
A patient complained the Trust failed to diagnose a haematoma and communicate a positive COVID-19 test result, resulting in a second surgery, pain, and lost income.
NHS in England
Oct 2023
P-002519 — A practice in the Colchester area
Mrs R complained a GP practice, Ambulance Trust, and Hospital Trust failed to diagnose and treat her mother's swollen foot and PAD, and the hospital failed to prevent COVID-19, leading to her death.
NHS in England
Mar 2024
P-003234 — Tameside and Glossop Integrated Care NHS Foundation Trust
Miss G complained the Trust delayed acting on Mr H's lung disease diagnosis, preventing treatment, and failed to notify his brothers of risks, contributing to his death.
NHS in England
Partly Upheld
Dec 2024
P-003247 — Chesterfield Royal Hospital NHS Foundation Trust
Mr B alleged his father contracted COVID-19 without treatment, was discharged without proper assessment or oxygen, experienced poor communication, and had a heart attack unrecognized for days.
NHS in England
Dec 2024
P-001653 — University Hospitals Coventry and Warwickshire NHS Trust
The Trust failed to inform family or district nurses about L's ankle sores developed in hospital, and discharge notes were inadequate. This caused distress during L's final days.
NHS in England
Partly Upheld
Dec 2022
P-002005 — East Kent Hospitals University NHS Foundation Trust
Mrs A complained about inadequate oncology and neurology care for Mr A, including incorrectly reported scans, a missed brain tumour diagnosis opportunity, and failure to provide pain relief.
NHS in England
May 2023
P-002420 — Gateshead Health NHS Foundation Trust
Mr A complained the Trust failed to biopsy or regularly scan a lung growth from 2017-2019, delaying a cancer diagnosis until it had spread, increasing his distress.
NHS in England
Jan 2024
LGO / SPSO decisions(16)
NIPSO-202002039 — Western Health and Social Care Trust
A teenage boy waited 18 months to see a consultant after he was diagnosed with arthritis and ruptured ligaments. We asked the Trust to apologise for the failures which caused the delay.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Dec 2023
24-016-431 — City of Bradford Metropolitan District Council
Summary: Mrs X complained the Council incurred delays in considering her application for a Disabled Facilities Grant for her son. She also complained the Council did not properly consider her application. Mrs X said the Council’s actions caused avoidable distress to her son and the family. The Council is at …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2025
20-012-668a — Royal Wolverhampton Hospital NHS Trust (20 012 668a)
Summary: The Ombudsmen find a Nursing Home, Hospital Trust and Ambulance Trust responded appropriately when a Nursing Home resident became unwell in March 2020. Based on the evidence seen to date, professionals completed appropriate assessments and acted in line with guidance in place at that time. There was fault in …
LGO (Local Government & …
Health
Not Upheld
Mar 2022
25-001-856 — London Borough of Barking & Dagenham
We will not investigate Mrs X’s complaint about the Council’s decision to decline an Education, Health and Care Needs Assessment and the delay in providing a decision. This is because it would be reasonable for her to use her right of appeal to a tribunal and there is not sufficient …
LGO (Local Government & …
Education
Jun 2025
NIPSO-201913103 — Belfast Health and Social Care Trust
Our investigation found failings in the care and treatment provided to a cancer patient by the Belfast Health and Social Care Trust.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2023
20-010-783b — Gloucestershire Hospitals NHS Foundation Trust (20 010 783b)
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Health
Upheld
May 2022
20-010-783a — Gloucestershire Hospitals NHS Foundation Trust (20 010 783a)
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Health
Upheld
May 2022
201102400 — Highland NHS Board
Mrs C was admitted to hospital for a gastroscopy (a procedure in which a thin, flexible tube is used to look inside the stomach) under general anaesthetic. She waited in the day room until she was allocated a bed. During this time a member of staff discussed confidential information with …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2012
201004951 — Fife NHS Board
Mrs A was admitted to hospital on numerous occasions in the two years before her death. She had a complex medical history and tested positive for a bacterial infection, Methicillin-resistant Staphylococcus aureus (MRSA), on six occasions during that time. Mrs A's daughter (Mrs C) complained that the board failed to …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2012
201400264 — Highland NHS Board
Ms C, an advocate, complained on behalf of her client (Mr A) about the infection control procedures used by Raigmore Hospital when he had a total hip replacement. When Mr A attended the pre-operative assessment when he was first scheduled for surgery, it was found that he had an in-growing …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2015
201708720 — Lothian NHS Board - Acute Division
Mrs C complained about the care her mother (Mrs A) received at St John's Hospital. Mrs C complained about the number of ward moves that Mrs A experienced. Mrs A had dementia and Mrs C said that the number of ward moves caused Mrs A to become disorientated. Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2018
202104334 — Lothian NHS Board - Acute Division
C complained about the care and treatment their late parent (A) received. A had a diagnosis of small cell lung cancer and was transferred to the Western General Hospital for urgent treatment of metastatic lung cancer. This was during the first year of the COVID-19 pandemic. Shortly after A's admission, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2022
202106371 — Lanarkshire NHS Board
C complained that the board failed to provide reasonable care and treatment to their late parent (A), who died following an admission to hospital. This included issues relating to A contracting COVID-19, that the board unreasonably failed to carry out an SAER/independent review, and that the board failed to reasonably …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2023
202104888 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment that their late parent (A) received from the board following A’s admission to hospital having suffered a stroke. A developed COVID-19 symptoms and this was confirmed by a positive swab. A’s condition deteriorated with them developing COVID-19 pneumonia and they sadly died. C …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2024
24-011-905 — Sheffield City Council
Summary: We will not investigate Mr X’s complaint about the Council’s refusal to carry out additional work to fix issues, he said were caused by building works the Council completed under a Disabled Facilities Grant. This is because
LGO (Local Government & …
Adult Care Services
Dec 2024
24-009-591 — Somerset Council
Summary: We will not investigate this complaint about delays in completing a disabled facilities grant adaptation. There is no worthwhile outcome achievable by our investigation.
LGO (Local Government & …
Adult Care Services
Dec 2024