Delayed Recognition of Deterioration
Failure to timely recognize, report, and escalate deteriorating patient conditions, leading to delayed intervention.
Source spread
Where this theme appears
This theme appears across 24 independent accountability sources, so the source mix matters as much as the headline total.
10 inquiry recs
430 PFD reports
16 committee recs
63 HSSIB recs
245 CQC actions
27 PPO recs
2 IOPC recs
14 IMB recs
5 IMB reports
1 patient safety alert
6 Scottish FAIs
1 Article 2 learning point
24 DHR recs
746 PHSO decisions
332 LGO/SPSO decisions
2 DSA service inquiries
16 CQC enforcement actions
1 LeDeR report
4 MNSI reports
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(10)
63 — Basic training on dealing with prisoners
Recommendation: That part of the basic training course for new prison officers which focuses on the development of their inter-personal skills should be reviewed in the light of this report and the lessons to be learned from Zahid’s murder. In particular, …
Unknown
55 — Wing officers calling for reviews
Recommendation: Wing officers should be reminded of the need to call for a review of an assessment when the necessity for one is triggered by some occurrence which might affect the prisoner’s emotional well-being.
Unknown
1 — CCTV and monitoring
Recommendation: All cots and incubators in all neonatal units should be fitted with baby monitors (in-cot cameras with livestreaming video), so that parents can observe their baby remotely at any time. The funding for this should be centrally managed and ring-fenced, …
Gov response: On safety and reassurance for parents, Lady Justice Thirlwall recommends the introduction of video baby monitors for neonatal units. I agree. I have asked my officials to urgently develop plans for cot cams, which can …
Accepted
40 — Process variables in the Control Room
Recommendation: Key process variables, as determined by the Safety Case, should be monitored and controllable from the Control Room (para 18.36).
Unknown
IBI-6a(vi) — Commissioning Hepatology Services
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy …
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
IBI-6a(v) — Consultant Hepatologist Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, …
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted in part
IBI-6a(iv) — Fibroscan for Liver Imaging
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be used for liver imaging, rather than alternatives
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
IBI-6a(iii) — Uncertainty About Fibrosis
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
IBI-6a(ii) — Specialist Hepatology Centre Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted in part
IBI-6a(i) — Hepatologist Oversight and Fibroscan Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical …
Gov response: We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease was acquired, …
Accepted
Prevention of Future Deaths reports(430)— showing 50 strongest matches
Keward Guy Domonic Harding
Concerns: An urgent mental health assessment, requested on March 19th, 2013, was not completed before April 2nd, 2013. A timely visit by a health professional may have detected a decline in physical health, potentially allowing for active treatment to prevent death.
Overdue
Luna Lesko
Concerns: The coroner noted delays in securing foetal monitoring and in performing a Category 2 C-section delivery, which exceeded Trust guidelines due to busy theatres. Expert evidence identified a real risk of preventable death due to insufficient out-of-hours theatre capacity.
Response (Lewisham Greenwich NHS Trust): • The Trust confirmed the introduction of middle grade obstetricians and anaesthetists from 2012 to ensure adequate cover for multiple emergency caesarean sections. • The Trust proposed to implement a … (AI summary)
Overdue
Lucy Kilvert
Concerns: The coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
Overdue
James Edward Mansfield
Concerns: The GP surgery experienced delays in receiving and reviewing hospital discharge letters, lacking a method to differentiate between serious and non-serious injuries for prompt attention. Strong painkillers were prescribed over the phone without a face-to-face review, despite the patient's complex medical history and multiple rib fractures.
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise an acutely unwell resident or act on low blood pressure, exacerbated by a lack of ongoing training. Managers also did not effectively investigate incidents and provided inaccurate reports to the Care Quality Commission.
Overdue
Barbara White
Concerns: The coroner noted a lack of clinical observations and an incorrect PARS score delaying medical intervention. Concerns also included unescalated insufficient staffing on the surgical unit and communication gaps during handover, affecting subsequent clinical consideration.
Overdue
Jude Augustus Gordon
Concerns: The coroner noted failure to escalate care despite a marked increase in the Early Warning Score (SHEWS) and miscalculations. Concerns included the absence of a national, standardised Early Warning Score system and automatic alerts for deteriorating patients.
Response (Department of Health): • The Royal College of Physicians published a report in July 2012 advocating a National Early Warning Score (NEWS) to standardise acute illness assessment. • Clinical observation charts and e-learning … (AI summary)
Responded
Caroline Lee
Concerns: The coroner identified a lack of recognition by medical staff regarding the significance of potassium results and insufficient communication from the laboratory to ward staff about abnormal results.
Overdue
Selina Broadhurst
Concerns: The coroner raised concerns that NICE Guidelines for head CT scans, which require obvious neurological signs, may lead to missed or delayed diagnosis of severe brain injuries in frail elderly patients.
Overdue
Edna Elsie Mary Eden
Concerns: The coroner identified delays in a patient receiving prescribed antibiotics and doctor review, alongside infrequent nursing observations and an incorrect EDOD score that prevented escalation. Communication gaps meant nurses struggled to contact doctors, and junior staff did not escalate significant backlogs or concerns.
Response (Heatherwood Wexham Park Hospital NHS Trust): • The Trust introduced Policy TPP 231 in August 2013, which includes requirements for verifying EDOD score calculations and strengthens the use of the SBAR communication tool. • A new … (AI summary)
Responded
Stephen Palmer
Concerns: Concerns were raised regarding delays in surgical assessment and recognition of patient deterioration, along with an inappropriate unit transfer. The report also identified suboptimal clinical management, inadequate ward rounds, and a complete failure of the hospital's CT scanning service.
Overdue
Herta Woods
Concerns: Concerns were raised regarding a lack of early senior review for incorrect fluid charting, which contributed to fluid overload, and a failure to record doctor's visits and act on the patient's NEWS score.
Overdue
Nathan Douthwaite
Concerns: The coroner identified that a rectal biopsy might have led to an earlier diagnosis of Hirschsprung's disease, and recommended reviews of NICE guidelines, hospital practices, and potential guidance from the Department of Health.
Response (Department of Health): • NICE stated it would shortly begin a search for evidence to inform a review of its clinical guidance on constipation in children and young people. • NICE confirmed it … (AI summary)
Overdue
Margaret Easterfield
Concerns: The coroner raised concerns regarding the incidence of anastomotic leaks following surgery, noting its relative rarity and the potential implication of technical error by the surgeon.
Overdue
Noel Williams
Concerns: The coroner noted a failure to communicate recent haemoglobin test results to the anaesthetist and surgeon, which was important for assessing the patient's fitness for surgery. This gap in communication could lead to future deaths.
Overdue
Jean James
Concerns: The coroner identified delays in initial documentation, an unreviewed omission of prophylactic Dalteparin, and ineffective communication of a pharmacy query. Concerns were also raised that existing systems and policies may not be robust enough to manage human factors.
Response (City Hospitals Sunderland): • The Trust reviewed its hospital information system (MEDITECH V6) and is implementing updates to automatically prompt VTE medication prescriptions and alerts. • The Trust introduced a new patient-focused format … (AI summary)
Responded
Matthew Simmonds
Concerns: The coroner noted that a local action plan for complex care pathways, particularly for ventilated patients discharged to the community, has not been shared with other Clinical Commissioning Groups, limiting its potential to prevent similar deaths nationally.
Overdue
Kerry Jacobs
Concerns: The coroner noted a lack of documentation for steroid prescriptions outside usual guidelines and insufficient communication with the consultant. There was also no protocol for pharmacists to discuss queried dosages with clinicians.
Response (Surrey Sussex Healthcare NHS Trust): • A directive has been issued requiring staff to record the rationale for prescribing medication outside BNF guidelines and to document discussions with pharmacists regarding queried prescriptions. • The Chief … (AI summary)
Responded
John Dodd
Concerns: The coroner noted the patient's INR was not checked despite being on Warfarin and having a fall history. Concerns were also raised about an unreported temperature rise to medical staff and a significant delay in A&E assessment leading to a delayed diagnosis.
Response (The Dudley Group NHS Foundation Trust): • A written guideline will be developed for routine INR checks for patients on anticoagulants presenting after a fall. • An audit process will be developed to review the appropriate … (AI summary)
Responded
Gary Bradshaw
Concerns: The coroner noted delays in diagnosis, issues with incomplete blood test reporting, and medication prescribed before test results were known. Concerns also included an insufficient threshold for flagging critical blood-calcium levels, inadequate record-keeping, and apparent gaps in patient escalation to intensive care.
Response: • Staff have been reminded of the correct electronic and handwritten procedures for ordering blood tests, and consultants have been instructed to follow up on all ordered investigations. • Trust … (AI summary)
Response (Department of Health): • The Department of Health noted that the National Institute for Health and Care Excellence (NICE) would develop a guideline on renal stones. • The Department of Health noted that … (AI summary)
Responded
Gregg O’Reilly
Concerns: The coroner identified a missed opportunity by multiple medical and nursing teams to refer Mr O'Reilly to critical care, meaning he did not receive optimal care. Furthermore, observation records were missing for a significant period despite two-hourly monitoring being required.
Response (Barts Health NHS Trust): • The Trust stated it would recruit a Band 7 Sister for the relevant ward. • The Trust committed to developing formal guidelines for Critical Care Outreach Team medical reviews. … (AI summary)
Responded
Frances Bell
Concerns: The coroner noted the absence of a Root Cause Analysis investigation, a lack of input from senior clinical staff at the time of presentation, and an unacceptable delay between readmission and arrival in theatre.
Overdue
Samuel Openshaw
Concerns: The coroner raised concerns about the slow electronic transfer of echocardiograph studies to tertiary centres and the workload pressures experienced by specialist paediatric retrieval teams.
Overdue
Peter Hinchliffe
Concerns: The coroner raised concerns regarding delays in private sector investigations requiring NHS transfer, inconsistencies in advice for young athletes with syncope, and the lack of a consistent national approach to managing such cases.
Overdue
Ashley Ponsonby
Concerns: The coroner identified a lack of staff training in managing risks from illicit substance use on wards with dual diagnosis patients. Concerns were also raised about the failure to use incident reporting systems for drug supply/consumption, and the absence of a clear policy between the Mental Health Trust and Police regarding illegal activity.
Response (Greater Manchester Police): • Greater Manchester Police (GMP) developed a comprehensive Mental Ill Health and Learning Disabilities Policy in April 2013 to clarify police engagement with other agencies on mental health matters. • … (AI summary)
Responded
Albert Flynn
Concerns: Care staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Response (Lester Aldridge LLP): • The organisation stated it would re-emphasise the need to call for qualified assistance during individual staff supervision and new staff induction. • Senior care staff involved in the incident … (AI summary)
Responded
Peter White
Concerns: The coroner noted concerns regarding the hospital's Early Warning Observation Chart system, specifically its incorrect completion, ignored triggers, and lack of review by qualified staff. There is also no regular audit system to ensure proper use of the charts.
Overdue
Joyce Nelson
Concerns: The coroner identified significant delays in doctor assessment and documentation of X-ray results in the Emergency Department due to staff busyness. There were also considerable delays in imaging result reporting, which nearly led to the discharge of a patient with a multi-fractured pelvis.
Overdue
Evelyn Smith
Concerns: The coroner noted difficulties with accurate and consistent recording of vital signs and integrating the Paediatric Early Warning Scoring system into GP medical records. Additionally, the GP computer system does not alert clinicians to complete relevant clinical parameters, such as a croup severity score, after a diagnostic code is entered.
Overdue
Linda Rignall
Concerns: A change in Linda Rignall's condition, recorded on the NEWS Observation chart, was not reported to a doctor on the Acute Medical Unit nor was she assessed.
Overdue
Mr Pether
Concerns: The coroner noted a lack of focused checks on Mr Pether's limb viability and no re-evaluation of treatment options despite significant delays. The orthopaedic team also did not identify the source of infection even after his clinical condition deteriorated.
Overdue
Ella Block
Concerns: The coroner noted a missed opportunity to provide suitable treatment and identified that new clinicians may not readily recognise sepsis deaths in children due to the rarity of such cases.
Overdue
Stephen Atherton
Concerns: Delays occur in patients receiving additional investigations because radiologists recommend tests that GPs must request, even when GPs cannot directly instigate them. This process, influenced by commissioning arrangements, could increase the risk of future deaths.
Overdue
Yaser Saleh
Concerns: The EMIS computer system for GPs only flags patients for review if they are on current regular prescriptions, meaning those with chronic diseases who have stopped treatment are not identified for necessary monitoring. This poses a risk of preventable deaths for patients with conditions like asthma and epilepsy.
Overdue
Kirsty Pritchard
Concerns: Communication issues meant post-discharge patient contacts indicating worsening symptoms were not reported to the inpatient Consultant for timely self-harm risk assessment. There were also deficiencies in systems for quickly locating patients identified as having an immediate risk of self-harm.
Response (Black County NHS Trust): • The Trust strengthened in-reach to inpatient settings and reinforced communication with consultants by recirculating the medical escalation flow chart. • A protocol was developed for CHTT staff to follow … (AI summary)
Responded
Sonielia Holmes
Concerns: The coroner raised concerns regarding the inability to contact the Haematology Department and a lack of response from haematologists to messages seeking advice or patient review, identifying this as a risk to patient lives.
Overdue
Agnes Hannan
Concerns: The coroner raised concerns regarding the lack of available hospital notes, poor communication among staff and with the patient's family, and inadequate patient monitoring. Further issues included consultant allocation and the process for initiating end-of-life care without sufficient family discussion.
Response (Tameside Hospital NHS Trust): • The Trust has implemented a new computer system for medical records and replaced the PARS observation system with the NEWS system, providing staff training for both. • A review … (AI summary)
Responded
Sandra Higham
Concerns: The coroner raised concerns about the difficulty in diagnosing atrial-oesophageal fistula, a rare but high-mortality risk of ablation procedures, due to its non-specific symptoms and a lack of awareness within the wider medical profession.
Response (BHRS): • BHRS will publish an article on the avoidance and recognition of atrial-oesophageal fistula in its winter newsletter for members. • BHRS will remind members to ensure atrial-oesophageal fistula is … (AI summary)
Response (UK Health Security Agency): • Public Health England stated it was unable to directly assist with the case. • It noted that the Department of Health would contact appropriate bodies, such as the British … (AI summary)
Response (Department of Health): • Officials contacted the Royal College of Surgeons, the Society for Cardiothoracic Surgery, and the British Cardiovascular Society regarding the concern. • Officials reported that the British Cardiovascular Society is … (AI summary)
Responded
Mary Hallworth
Concerns: Medical attention for the deceased was not sought or considered for 24 hours following a fall, despite the person experiencing pain.
Overdue
Mark Hudson
Concerns: The coroner raised concerns that urgent requests for specialist care within the CICU department may be delayed or unanswered. This is due to procedures for CICU staff requesting assistance via the Hospital Switchboard being insufficiently robust.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): • The Resuscitation Team undertook training with senior members of the Cardiac Intensive Care Unit team on iGel tube placement. • The Trust adopted a policy of using end tidal … (AI summary)
Responded
Peter Dorney
Concerns: The coroner identified that the Early Warning Score (EWS) protocol was not followed and EWS training for nurses is not mandatory, despite its importance for patient well-being.
Response (North Bristol NHS Trust): • The Trust stated that all new nurses receive mandatory Early Warning Score (EWS) training during induction. • Following the Regulation 28 report, the Trust reviewed staff training records and … (AI summary)
Responded
Harold Penny
Concerns: The coroner noted a lack of a system requiring the radiology department to either rectify a displaced urinary catheter or urgently report such findings to treating clinicians.
Response (Tameside Hospital NHS Trust): • The Trust produced a draft 'Radiology Requesting and Reporting Policy' which is undergoing governance procedures and is scheduled for review in February 2015. • A Results Governance Steering Group … (AI summary)
Responded
Stephen Mayoll
Concerns: Out-patients returning to the fracture clinic were not re-assessed under the DVT policy, potentially increasing DVT risk. Additionally, delays in typing doctors' notes meant they were not always available for follow-up appointments.
Response (Portsmouth Hospitals NHS Trust): • Patients returning to the fracture clinic with lower limb injuries will undergo VTE risk factor reassessment at each visit. • A plaster room form is being updated to incorporate … (AI summary)
Responded
Freda Owens
Concerns: The coroner noted insufficient quality in information gathering and exchange among medical professionals, including an inadequate examination by a District Nurse and a lack of communication between hospital teams, which delayed specialist assessment.
Overdue
Mikey Hornby
Concerns: Concerns were raised that out-of-hours staff did not immediately send the child to hospital for an infected umbilical cord, and a doctor later failed to appreciate the seriousness of the situation, sending the child home. The coroner also noted the GP surgery's lack of facilities for simple blood tests.
Response (Bridgewater Community Healthcare NHS Trust): • The Trust implemented national NICE guidance on feverish illness in children and uses the Paediatric Early Warning Score (PEWS) system in its out-of-hours service. • A Root Cause Analysis … (AI summary)
Responded
David Mountain
Concerns: The coroner raised concerns that risks of bleeding and vascular damage after pacemaker insertion were not fully investigated despite the patient developing chest pain. An echocardiogram showing a bleed was significantly delayed and its results were not available before the patient's death.
Response (The Queen Elizabeth Hospital): • The Trust has undertaken a detailed analysis of the death and spoken to all clinicians involved in care. • Cardiac technicians now directly contact clinical teams for abnormal results, … (AI summary)
Responded
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
Susanna Geraty
Concerns: Inadequate post-operative fluid balance assessment, monitoring, and recording, alongside insufficient nursing records, were identified. The coroner also noted a failure to recognise the patient's acute illness and respond to family concerns.
Response (Surrey Sussex NHS Trust): • The Trust implemented new Early Warning Score (EWS) paperwork in January 2014 and provides regular training, including SBAR communication guides and pads introduced to wards in January 2015. • … (AI summary)
Responded
Lana-Liza Chervonenko
Concerns: Insufficient medical cover and high activity on the labour ward led to delays in patient review, documentation errors, and communication gaps between clinical teams. The coroner also noted no system existed for theatre staff to proactively notify treating teams of theatre availability.
Overdue
Brian Marks
Concerns: The coroner noted the similar appearance of PEJ and PEG tubes could lead to confusion, suggesting a simple colour coding system to aid differentiation when the tubes are in situ.
Response (Department of Health): • The Medicines and Healthcare Products Regulatory Agency (MHRA) will bring the issue of tube misidentification to the attention of relevant Standards Committees. • The MHRA will include the risk … (AI summary)
Responded
Select committee recommendations(16)
#10 — Long elective care waiting times pose serious risks to patient health and mortality
Recommendation: We received written evidence that long waiting times can put patients at risk. Evidence from Dr Rob Findlay noted that if it is not known what is wrong with undiagnosed patients then some of them will unexpectedly turn out to …
Response attribution not verified
#20 —
Recommendation: The OfS should prioritise holding discussions with providers more regularly about their financial situation, in particular those that are not considered high-risk.
Response attribution not verified
#19 —
Recommendation: The OfS’ targeted approach can mean it communicates little with institutions whose financial data appears healthy. This limits the regulator’s knowledge of providers that are not in financial difficulties, makes it harder to identify risks that are not evident in …
Response attribution not verified
#9 —
Recommendation: In 2024–25, 32 of 106 local NHS areas (known as sub-ICBs) assessed less than 10% of their registered patients aged 65 or over. However, nine of 106 local areas assessed 90% or more of this group of people, suggesting that …
Response attribution not verified
#7 —
Recommendation: We praise prison staff, HMPPS and MoJ officials for their work in responding to the Covid-19 pandemic. The virus has brought into sharp relief many of the issues affecting the prison system, including the particular health vulnerabilities of older cohorts. …
Response attribution not verified
#48 — Update Women's Health Strategy to prioritise specific conditions and reduce endometriosis diagnosis waiting times.
Recommendation: The Women’s Health Strategy for England should be updated to include priorities for specific, common conditions. We recommend the Government commits to reducing waiting times for an endometriosis diagnosis to less than two years by the end of this Parliament …
Response attribution not verified
#39 — Train primary care practitioners to identify hidden reproductive health concerns during routine interactions.
Recommendation: Primary care practitioners should be trained to use women’s common interactions with the healthcare system, such as cervical screening appointments, ante- and post-natal care checks and visits to STI clinics, as an opportunity to pick up hidden health concerns relating …
Response attribution not verified
#20 —
Recommendation: Despite the DVLA clearing the backlog in most driving licence applications by mid- 2022, there remains a backlog in applications that involve the DVLA making a medical decision. Processing times for applications that involve such decisions are still far longer …
Response attribution not verified
#5 —
Recommendation: The DVLA’s system to process applications from customers who have notified it of relevant medical conditions is slow, inefficient and in need of major improvement. Processing times for applications that involve the DVLA making a medical decision are far longer …
Response attribution not verified
#10 —
Recommendation: We recognise that reducing waiting times is vital to ensuring people get the support that they need. However, we are keenly aware that delays are still happening. In line with our recommendation that the Department set clearance time targets, we …
Response attribution not verified
#9 —
Recommendation: The application and assessment process can be very stressful for claimants, and unacceptable delays are exacerbating these problems. We recognise that waiting times have begun to fall but are concerned that with increasing demand this could be a recurring problem. …
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
#73 —
Recommendation: Comprehensive analysis should be carried out to assess the safety of running the NHS with the limited latent capacity that it currently has, particularly in Intensive Care Units, critical care units and high dependency units.
Response attribution not verified
#3 —
Recommendation: We have heard of the importance of receiving a timely diagnosis for people with dementia and their carers. We appreciate that the covid-19 pandemic will undoubtably have played a part in the recent decline in diagnosis rates which was previously …
Response status not verified
#4 —
Recommendation: It will be very challenging for the NHS to focus sufficiently on the needs of patients when it comes to dealing with backlogs, both patients already on waiting lists and those who have avoided seeking or been unable to obtain …
Response attribution not verified
#13 — Delays in public health and substance misuse grant allocations impede local authority planning and commissioning.
Recommendation: DHSC is responsible for allocating the annual Public Health Grant and Supplementary Substance Misuse Treatment and Recovery Grant to local authorities each year. The NAO’s report highlighted that there had been significant delays in confirming allocations of these grants for …
Response attribution not verified
HSSIB safety recommendations(63)— showing 50 strongest matches
Timely detection and treatment of cauda equina syndrome
The regional specialist spinal centre described in this report has worked with the electronic referral system manufacturer to ensure alerts are received by neurosurgical doctors. This has included doctors having a single ‘baton’ telephone that receives the alert, with the …
Safety Action
Timely detection and treatment of cauda equina syndrome
It may be beneficial for safety-netting leaflets to be given to patients with low back and radicular pain. Leaflets should use clear and concise language, and provide clear directions as to what a patient should do if they develop red …
Safety Observation
Patient care in temporary care environments
Does your organisation have a way of displaying clinical information and observations of patients in a temporary care environment to all relevant staff, so that trends or deterioration in a patient’s condition can be identified?
Learning Prompt
Insulin: supporting safe administration in inpatient settings
HSSIB recommends that the Royal College of Physicians reviews and acts on new data and outcomes of studies about adopting blood glucose into NEWS2 and shares any decisions it makes. This is to encourage understanding and support consideration of how …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation ensure long-term condition reviews reliably take place for patients who may be at a higher risk of deterioration due to their circumstances, for example those with multiple long-term conditions?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
Does your organisation have systems and processes to identify where patients have not requested their repeat medication prescription, or the frequency of the requests have changed, which may indicate changes in their circumstances?
Learning Prompt
Recognising and responding to critically unwell patients
NHS England/NHS Improvement should expand the remit of the Cross-System Sepsis Programme Board to include physical patient deterioration, involving additional stakeholders as required. HSIB makes the following safety observations Observations: NEWS2 is not intended to be a stand-alone tool. Instead, …
Safety Recommendation
Recognising and responding to critically unwell patients
It is recommended that the Royal College of Physicians NEWS advisory group continues to evaluate the implementation and use of NEWS2, including but not limited to: The use of NEWS2 in practice, in particular the consistency of recording, the consistency …
Safety Recommendation
Delayed recognition of acute aortic dissection
In release 18, NHS Digital has amended the content of the NHS Pathways algorithm used for telephone triage of patients, to help improve recognition of chest pain likely to be associated with acute aortic dissection.
Safety Action
Delayed recognition of acute aortic dissection
Current recommendations for all patients with acute aortic dissection specify immediate measures to control blood pressure and heart rate. Non-specialist hospitals which may dispatch these patients to specialist centres might wish to review their guidance and instructions to staff in …
Safety Observation
Delayed recognition of acute aortic dissection
It would be beneficial if the providers of emergency department triage systems were to consider the addition of ‘aortic pain’ as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.
Safety Observation
Delayed recognition of acute aortic dissection
It is recommended that the Royal College of Emergency Medicine, together with the Royal College of Radiologists, develops, deploys and evaluates a national evidence-based process to detect and manage patients with acute aortic dissection presenting to emergency departments. The process …
Safety Recommendation
Delayed recognition of acute aortic dissection
It is recommended that the Manchester Triage International Reference Group considers the addition of ‘aortic pain’ to the Manchester Triage System as a discriminator for chest pain, to raise awareness of acute aortic dissection as a potential cause.
Safety Recommendation
The diagnosis of ectopic pregnancy
The National Institute for Health and Care Excellence should review and revise the clinical knowledge summary for ‘urinary tract infection (lower) – women’ to include ectopic pregnancy as a category under ‘alternative or serious diagnoses’.
Safety Recommendation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
the likely time course of the illness and when to re-present to healthcare services
Learning Prompt
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
It may be beneficial if written safety netting advice is developed for pregnant and postpartum women about COVID-19 and other common conditions, incorporating the MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) recommendations. Related …
Safety Observation
Emergency response to heart attack
It may be beneficial if further work was conducted to identify the impact of delays in primary percutaneous coronary intervention on the morbidity of patients, and longer-term mortality of patients, suffering from ST-elevation myocardial infarction.
Safety Observation
Emergency response to heart attack
It may be beneficial if NHS emergency call handling triage systems consider how intelligent analytics or increased clinical oversight may be enhanced to assist in the early identification of STelevation myocardial infarction calls.
Safety Observation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS Digital reviews the supporting information for triaging the breathless child up to 16 years of age, to determine whether there are features of life-threatening breathing difficulty.
Safety Recommendation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that NHS England and NHS Improvement develops a national cauda equina syndrome pathway. This should define the safety-critical elements of the pathway and highlight areas that can be adapted locally
Safety Recommendation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that guidance is developed by the Royal College of Radiologists, supported by the Society and College of Radiographers, stating that all hospitals should reserve the first MRI slot of the day for patients with suspected cauda equina syndrome …
Safety Recommendation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that the British Association of Spine Surgeons oversees the development of national guidance to identify how ‘urgent’ and ‘emergency’ requests for scans for suspected cauda equina syndrome are defined and prioritised
Safety Recommendation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that the British Association of Spine Surgeons, supported by the Royal College of Surgeons of England and the Royal College of Emergency Medicine, develops a decision-making tool to support the identification of patients who need an immediate MRI …
Safety Recommendation
Recognition of the acutely ill infant
It may be beneficial if further research and observational studies are carried out to examine how listening to parents [or taking on board parents’ views/concerns] impacts on clinical decision making and recognition of the sick infant/child. The intention of the …
Safety Observation
Recognition of the acutely ill infant
It may be beneficial if NHS England and NHS Improvement’s System-wide Paediatric Observations Tracking (SPOT) Programme considers visual representation of critical information (such as a clinical intervention administered) and the potential impact of these interventions on an infant’s/child’s PEWS.
Safety Observation
Recognition of the acutely ill infant
It may be beneficial if the research studies recommended by the National Institute for Health and Care Excellence are conducted in primary care and secondary care to determine whether examination or re-examination after a dose of antipyretic (temperature reducing) medication …
Safety Observation
Clinical decision making: diagnosis of pulmonary embolism in emergency departments
It may be beneficial for emergency departments and same-day emergency care units to have rapid access to recommended imaging for patients who require it for the diagnosis of pulmonary embolism.
Safety Observation
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
It may be beneficial to review triage software and safety-netting/worsening advice to ensure the language used by health advisors does not deter seriously unwell people from calling back or seeking medical advice if necessary.
Safety Observation
Detection of jaundice in newborn babies
HSIB recommends that the Royal College of Pathologists works with stakeholders to understand current practice and make any appropriate recommendations to promote the adoption of an icteric threshold at which a bilirubin test may be cascaded or reported.
Safety Recommendation
Assessment of risk during the maternity pathway
the parameters for assessing progress in labour and timely intervention.
Learning Prompt
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety in acute medical units by identifying and planning for the increased need for routine periodic and ongoing nutritional screening and monitoring to account for increased length of patient stays.
Learning Prompt
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety by supporting staff in acute medical units to complete and review MUST screening, identifying where a subjective assessment has been completed, and when further MUST screenings should take place.
Learning Prompt
Sepsis: a patient with abdominal pain
There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
Area of Improvement
Sepsis: a patient with abdominal pain
Staff perceive that a diagnosis of infection is needed before completing the sepsis screening tool.
Area of Improvement
Sepsis: a patient with abdominal pain
New confusion in patients is not consistently accounted for in NEWS2 scores.
Area of Improvement
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
There are challenges in how tools and processes enable the care of deteriorating patients to be escalated to, and overseen by, senior medical and nursing staff.
Area of Improvement
Timely detection and treatment of cauda equina syndrome
It may be beneficial for NHS spinal networks in England to implement services and processes to support timely access to MRI for patients with suspected cauda equina syndrome, in line with national guidance to be developed by the British Association …
Safety Observation
Timely detection and treatment of cauda equina syndrome
It may be beneficial for all hospitals where patients with potential cauda equina syndrome may present to have access to MRI scanning and reporting 24 hours a day, 7 days a week.
Safety Observation
Medication not given: administration of time critical medication in the emergency department
How does your organisation ensure that patients who need time critical medications are identified as soon as possible on arrival to the ED?
Learning Prompt
Undetected button/coin cell battery ingestion in children
It is recommended that the Royal College of Paediatrics and Child Health (RCPCH) develop a key practice point within a decision support tool for suspected or known ingestion of button/coin cell batteries, and to be supported in this development by …
Safety Recommendation
Management of acute onset testicular pain
It is recommended that the NHS England/Improvement ‘Getting It Right First Time’ (GIRFT) programme ensures that testicular torsion/acute testicular pain is included on the checklist of emergency pathways to be considered by the newly established Urology Area Networks across England.
Safety Recommendation
Management of acute onset testicular pain
It is recommended that the National Institute for Health and Care Excellence revises the content and accessibility of its Clinical Knowledge Summary on testicular torsion.
Safety Recommendation
Lack of timely monitoring of patients with glaucoma
It is recommended that the Royal College of Ophthalmologists agree criteria for the risk stratification of patients with glaucoma so that practice can be standardised across NHS hospital eye services.
Safety Recommendation
Lack of timely monitoring of patients with glaucoma
It is recommended that the Royal College of Ophthalmologists, working with relevant stakeholders, develop models and review workforce required for the optimal delivery of glaucoma care. The models should be tested and evaluated. It is recommended that the Royal College …
Safety Recommendation
The diagnosis of ectopic pregnancy
It is recommended that the Royal College of Obstetricians and Gynaecologists should provide guidance on the information that should be provided during referral to early pregnancy units to standardise and improve the flow of information required to identify those most …
Safety Recommendation
Early warning scores to detect deterioration in COVID-19 inpatients
The Royal College of Physicians has highlighted the issue of rapid deterioration in oxygenation in patients with COVID-19 and how this might relate to the use of early warning scores. Outcome: The RCP released a statement on its website relating …
Safety Action
Unplanned delayed removal of ureteric stents
The National Institute for Health and Care Excellence guidance for the management of urinary tract infections does not include ureteric stents as a cause of urinary symptoms which could mimic a urinary tract infection. It may be beneficial for this …
Safety Observation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
advice on potential alarming or warning symptoms
Learning Prompt
Timely detection and treatment of cauda equina syndrome
HSIB recommends that the National Institute for Health and Care Excellence updates its current low back pain guideline to include the symptoms and initial management of cauda equina syndrome. This update should include a review of the role of supplementary …
Safety Recommendation
Recognition of the acutely ill infant
HSIB recommends that NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT …
Safety Recommendation
NCEPOD recommendations(64)— showing 50 strongest matches
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
CQC inspection actions(245)— showing 50 strongest matches
Wexham Park Hospital
The service should ensure correct and effective use of MEOWS and NEWTT charts to accurately identify deteriorating patients.
Should Do
Wythenshawe Hospital
The service must ensure staff carry out effective monitoring of women, birthing people and babies during labour, including use of ‘fresh eyes’ in line with guidance. Regulation 12(1)(2)(a)(b)
Must Do
William Harvey Hospital
The trust must ensure all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
William Harvey Hospital
The trust must ensure that all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
Westmorland General Hospital
The trust should consider whether the triage service in the walk-in waiting area can be improved so that the triage nurse can observe patients in the waiting area more easily.
Should Do
Westmorland General Hospital
The service must ensure staff assess the risks to women during and after birth in order to identify women at risk of deterioration.
Must Do
Westmorland General Hospital
The service must ensure all women assessed as at risk of having sepsis receive care and treatment in line with national guidance and requirements.
Must Do
Westmorland General Hospital
The trust must operate an effective clinical escalation system to ensure stroke care and treatment is assessed and implemented in a timely way.
Must Do
Westmorland General Hospital
The trust must ensure all patients are clinically assessed and National Early Warning Scores are documented for all patients.
Must Do
Westmorland General Hospital
The service must ensure all women assessed as at risk of having sepsis receive care and treatment in line with national guidance and requirements.
Must Do
University Hospital Aintree
The trust must ensure that improvement work continues to deliver safe care and treatment to patients with suspected or confirmed sepsis.
Must Do
The York Hospital
The service should ensure service staff are trained in sufficient numbers to recognise or respond to the warning signs of sepsis in patients.
Should Do
The York Hospital
The service must ensure ED staff know about and deal with any specific risk issues such as patients at risk of sepsis. They must complete patient’s sepsis 6 care bundle paperwork including medication administration times, patient details and follow up …
Must Do
The York Hospital
The service must ensure the service improves compliance in sepsis screening, especially for patients receiving antibiotics within an hour. They must also ensure ED medical staff improve their overall training compliance rate in sepsis screening and all ED staff complete …
Must Do
The York Hospital
The trust must ensure that there is adequate oversight of the harms caused by delays to assessment and treatment.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure clinical observations, screening and testing are carried out in a timely way, reviewed, and any deterioration escalated.
Must Do
The Queen Elizabeth Hospital
The service must ensure staff escalate and document adverse baby observations.
Must Do
The Princess Royal Hospital
The trust should ensure that patients are screened and treated for sepsis in line with recommended guidance and trust policy.
Should Do
The Princess Royal Hospital
The trust should ensure that sepsis trolley within neonates is checked daily.
Should Do
The Princess Royal Hospital
The service should ensure that deteriorating patients are consistently identified and escalated in line with trust policy.
Should Do
Sunderland Royal Hospital
The trust must ensure staff undertake cardiotocographies (CTGs) and ensure this is recorded, assessed, monitored and escalated as appropriate with fresh eyes assessments.
Must Do
Sunderland Royal Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.
Must Do
Sunderland Royal Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.
Must Do
Sunderland Royal Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.
Must Do
Sunderland Royal Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.
Must Do
St Albans City Hospital
The trust should ensure that patients received antibiotics for the treatment of suspected sepsis in a timely manner (Regulation 12).
Should Do
South Tyneside District Hospital
The trust must ensure staff undertake cardiotocographies (CTGs) and ensure this is recorded, assessed, monitored and escalated as appropriate with fresh eyes assessments.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ mental health deteriorates.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately monitor, assess, and escalate when service users’ physical health deteriorates in line with best practice, this should be monitored and audited with actions taken to improve compliance.
Must Do
Scarborough Hospital
The service should ensure service staff are trained in sufficient numbers to recognise or respond to the warning signs of sepsis in patients.
Should Do
Scarborough Hospital
The service must ensure ED staff know about and deal with any specific risk issues such as patients at risk of sepsis. They must complete patient’s sepsis 6 care bundle paperwork including medication administration times, patient details and follow up …
Must Do
Scarborough Hospital
The service must ensure the service improves compliance in sepsis screening, especially for patients receiving antibiotics within an hour. They must also ensure ED medical staff improve their overall training compliance rate in sepsis screening and all ED staff complete …
Must Do
Scarborough Hospital
The trust must ensure that there is adequate oversight of the harms caused by delays to assessment and treatment.
Must Do
Salford Royal Hospital
This service should ensure tools to identify patients at risk of deterioration are used in an accurate and timely manner by staff.
Should Do
Salford Royal Hospital
The trust should ensure that patient observations are carried out in a timely manner.
Should Do
Salford Royal Hospital
The service must ensure they effectively assess risks to patients and do all that is possible to mitigate such risks. This includes but is not limited to risk relating to patients placed on corridors, patients awaiting triage and treatment, patients …
Must Do
Salford Royal Hospital
The service must ensure they effectively assess risks to patients and do all that is possible to mitigate such risks. This includes but is not limited to risk relating to patients placed on corridors, patients with suspected sepsis and other …
Must Do
Russells Hall Hospital
The trust should ensure they improve their performance in relation to their deteriorating patient pathway measures.
Should Do
Russells Hall Hospital
The trust should ensure they improve their performance in relation to their deteriorating patient pathway measures.
Should Do
Royal Shrewsbury Hospital
The trust should ensure that patients are screened and treated for sepsis in line with recommended guidance and trust policy.
Should Do
Royal Shrewsbury Hospital
The service should ensure that deteriorating patients are consistently identified and escalated in line with trust policy.
Should Do
Royal Preston Hospital
The trust must continue to take actions to improve the number of patients receiving a clinical assessment and daily review by a senior decision maker within target timescales.
Must Do
Royal Hallamshire Hospital
The trust must continue to implement effective systems to ensure staff consistently assess and manage risks in relation to service users whom may be deteriorating.
Must Do
Royal Hallamshire Hospital
The trust must implement an effective system to ensure all patients waiting to be admitted to the department from the ambulance queue are monitored for signs of deterioration.
Must Do
Rochdale Infirmary
This service should ensure tools to identify patients at risk of deterioration are used in an accurate and timely manner by staff.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that all staff maintain effective oversight of patients for the duration of their care within the ED. For example, ensuring patients are regularly assessed and reassessed clinically.
Must Do
Pilgrim Hospital
The trust should ensure deteriorating patients are identified and escalated in line with trust policy.
Should Do
PPO death in custody recommendations(27)
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff consistently use the National Early Warning Score 2 (NEWS2) to assess prisoners who are unwell and identify any clinical deterioration.
The Governor and Head of Healthcare at HMP Woodhill
The Governor and Head of Healthcare at Woodhill must ensure that urgent healthcare appointments are not delayed.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff follow the protocols for clinical escalation as per NEWS2 and sepsis pathways.
The Head of Healthcare
The Head of Healthcare should ensure that staff understand how to assess clinical deterioration including use of the NEWS2 tool.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff consistently use the National Early Warning Score 2 (NEWS2) to assess patients and are trained to use the appropriate scale for those with respiratory failure.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: are fully competent in using the National Early Warning Score (NEWS2) effectively; complete full and accurate clinical observations; follow protocols for clinical escalation in line with NEWS2 and sepsis pathways; and …
The Head of Healthcare
The Head of Healthcare should ensure staff use the best available evidence, including NEWS2 scores, when assessing prisoners’ physical health.
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of the Multi-Professional Complex Case Clinic (MPCCC) criteria and consider its early use for a patient who is deteriorating.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a MUST assessment when a person is weighed and ensure any concerns are escalated with immediate effect.
The Head of Healthcare
The Head of Healthcare should ensure that when patients are presenting with red flag symptoms an urgent chest X-ray is ordered under the 2-week guidelines and in accordance with NICE Guidelines NG12 suspected cancer: recognition and referral.
The Head of Healthcare
The Head of Healthcare should ensure that all patients who report that they feel clinically unwell, have a full set of clinical observations undertaken. They should also ensure that all staff are trained and competent in the use of the …
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that if staff notice that a prisoner has lost a significant amount of weight, they refer them to a medical professional who can assess them for possible causes.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review the systems and processes for prison staff to request a healthcare review of a prisoner with deteriorating health including how to apply the policy for calling emergency codes.
The Head of Healthcare
The Head of Healthcare should ensure that an ECG is undertaken promptly if a prisoner collapses without clear explanation, regardless of his physical presentation.
The Head of Healthcare
The Head of Healthcare should carry out an investigation into why Mr Connor’s rising PSA level was not acted upon between August and November 2024.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete a full set of clinical observations, including a NEWS2 score, when a prisoner requires a healthcare assessment, to ensure that patients who are deteriorating, or at risk of deteriorating will …
The Head of Healthcare
The Head of Healthcare should ensure that clinical staff receive training on when to make referrals under the two-week wait cancer pathway, in line with national guidance.
The Head of Healthcare
The Head of Healthcare to assure herself that the healthcare staff who undertake the role of Nurse in Charge on H3 have the sufficient skills and competencies to recognise a clinically deteriorating patient.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should formalise the way that PS incidents are assessed and the handover of care from healthcare to prison staff including: • The development and introduction of a PS assessment template for SystmOne, to include …
The Head of Healthcare at HMP Drake Hall
The Head of Healthcare at HMP Drake Hall should ensure that healthcare staff take appropriate action in response to abnormal readings for blood pressure and cholesterol, in line with the National Institute for Health and Care Excellence (NICE) guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that there is a system in place for prisoners with chronic disease to be monitored and assessed effectively.
The Head of Healthcare
The Head of Healthcare should ensure there is a system in place for GPs to follow-up and action abnormal blood test results and blood pressure readings.
The Head of Healthcare
The Head of Healthcare should ensure that a full set of clinical observations are taken during reception screening in accordance with NICE guidance and any anomalies escalated to a senior clinician.
The Head of Healthcare and the lead GP at HMP …
The Head of Healthcare and the lead GP should issue guidance on the management of suspected acute cardiac events which makes clear the schedule of prioritisation of emergency treatment and transfer of patients to appropriate emergency care.
The Head of Healthcare and the lead GP at HMP …
The Head of Healthcare and the lead GP should identify if there is a need for additional guidance and training for staff to support them to escalate the requirement for senior staff to support rapid assessment of undifferentiated sudden illness.
The Head of Healthcare
The Head of Healthcare should ensure that when staff take clinical observations, they: • record the readings in the prisoner’s medical record; and • calculate and record the NEWS2 score and know when to escalate care as a result.
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 …
IOPC learning recommendations(2)
Investigation into response to a concern for welfare - Greater Manchester Police, …
The IOPC recommends that Greater Manchester Police incorporates, if possible, a system prompt on ControlWorks specifically for control room supervisors to alert supervisors when a log has been unresourced for a period of time that exceeds the target for the …
Investigation into response to a concern for welfare - Greater Manchester Police, …
The IOPC recommends that Greater Manchester Police takes steps to ensure that the staff within the Force Control Centre understand the importance of the escalation policy and the individual responsibilities laid out within the policy for escalating incidents when they …
IMB annual reports(5)
London STHF (2024)
The London STHF IMB report highlights significant concerns regarding the treatment and conditions of detainees for the reporting year ending January 2024. Despite some positive observations in staff conduct and minor amenity improvements, critical issues persist with data provision for vulnerable adults and use of force, extended detainee waits in unsuitable facilities, and systemic failures in interpretation services and access to medication. The Board urges resolution of these long-standing problems.
PRISON
Key concerns
North East Midlands, Yorkshire & Humber STHF (2024)
The IMB report for North East Midlands, Yorkshire & Humber STHFs highlights varied conditions across the region's facilities, with particular focus on Swinderby RSTHF. While Swinderby benefits from positive staff-detainee relations and improved facilities, significant concerns persist regarding physical safety during building works, inadequate risk identification processes, and non-compliance with safer detention guidelines. Across all STHFs, the Board criticizes the policy on detainee medication, the unsuitability of some holding rooms, and restricted IMB access to essential documentation.
PRISON
Key concerns
Dartmoor (2024)
The report for HMP Dartmoor covers a year dominated by uncertainty and eventual temporary closure due to elevated Radon gas levels, leading to extensive prisoner decanting. While initial safety metrics remained low and in-cell phones improved wellbeing, the period was marked by delayed decision-making from HMPPS, significant estate deterioration, and challenges in maintaining a consistent regime and purposeful activity for the fluctuating population. Healthcare provision, despite a new provider, faced issues with staffing, 24-hour care, and external waiting times, while the Board expressed strong concerns about the lack of accountability from Ministers regarding previously raised recommendations.
PRISON
Key concerns
Garth (2020)
HMP Garth faced significant challenges during the reporting year ending November 2020, dominated by the COVID-19 pandemic. The Board commends the Governor and staff for their proactive measures, which successfully kept the prison safe and largely free of the virus among prisoners until October, while adapting the regime and maintaining essential services. Key concerns persist regarding the slow progress for IPP prisoners, lengthy investigations into deaths in custody, staff stress and recruitment, and long-standing issues with property transport and maintenance services.
PRISON
Key concerns
Brook House (2020)
In 2020, Brook House IRC faced significant challenges due to the COVID-19 pandemic, a contract change to Serco, and a compressed charter flight programme for Dublin Convention removals. The Board found the centre unsafe for vulnerable detainees in the latter months, marked by a dramatic increase in self-harm and suicidal ideation, and inhumane treatment of detainees due to Home Office policies. Delays in Rule 35 assessments, inadequate inductions, and issues with property and communication from the Home Office were key concerns, despite a welcome increase in staff numbers and some improvements in facilities.
PRISON
Key concerns
IMB individual recommendations(14)
Gatwick IRC (2021)
Systems and training should be improved, or additional resource provided if necessary, to ensure adequate and effective monitoring of men whose physical or mental condition may be deteriorating (sections 6.1, 6.3).
NHS / Healthcare Provider
Hollesley Bay (2023)
The need for hourly observations over prisoners arriving too late to be seen by the healthcare department highlights an important need. Those responsible for transport should be aware of those prisons without 24-hour healthcare provision.
HMPPS
Implemented
Altcourse (2023)
When will the statutory 28-day time limit for the transfer to hospital of prisoners requiring in-patient mental health treatment, referred to in the draft Mental Health Bill of June 2022, come into effect?
Other
In Progress
North East Midlands, Yorkshire & Humber STHF (2025)
In the light of delays in ambulance and paramedic attendance following an incident at Swinderby RSTHF, we recommend the use of ‘what3words’ or other precision location tools to aid navigation to places of detention and that lists of such places with the location details be readily available to paramedic crews. This is relevant not just for places such as Swinderby …
NHS / Healthcare Provider
North Sea Camp (2022)
Community offender managers often take a long time to update their part of OASys and complete the paperwork to enable prisoners to sit ROTL boards. This can mean prisoners having to postpone Parole Board hearings as they have not done the required ROTLs and means prisoners may spend more time in prison than strictly necessary. Timescales for return of paperwork …
HMPPS
Lowdham Grange (2022)
In its 2020-2021 report, the Board requested priority be given to holding coroners’ inquests for deaths in custody to provide bereaved families with an understanding of the circumstances of the deaths of their relatives. No inquests into deaths in custody at HMP Lowdham Grange have been held in the reporting period and this means that some families have been waiting …
Ministry of Justice
In Progress
Grendon (2022)
Reporting on response times to cell bells (4.2.4).
Governor / Director
Rye Hill (2024)
The Board was pleased that one terminally ill prisoner was given compassionate release during the reporting period. However, the Board is still concerned that the process remains unnecessarily difficult, particularly as it requires a GP’s diagnosis of terminal illness to be confirmed by a hospital consultant. The long waiting times to see an NHS consultant add unnecessary delays, which can …
HMPPS
Noted
Wandsworth (2025)
In October 2023, you wrote that the new healthcare centre would “open soon”. This has not happened. We repeat our question: why the delay and when will it open?
HMPPS
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB would like to have reassurance that centre protocols are to be revised to ensure that explicit procedures are in place to enable healthcare professionals (both internal staff and external paramedics) to attend health emergency incidents as quickly as possible – including the allocation of fast escort staff to facilitate this and the use of locational tools such as …
Other
Doncaster (2025)
The Board continues to be concerned over the number of cell bells unanswered within the timeframe required? Can the Director assure the Board that this remains a priority for the prison?
Governor / Director
In Progress
Ford (2023)
Last year, the Board reported on issues with outside probation that are affecting some men’s access to ROTL. The situation has not improved, although the problems/delays in communication are now mostly affecting the large proportion of prisoners with a London address. (7.3.2)
HMPPS
Ford (2023)
Last year, the Board reported on issues with outside probation that are affecting some men’s access to ROTL. The situation has not improved, although the problems/delays in communication are now mostly affecting the large proportion of prisoners who will return to their London home area. (7.3.2)
Ministry of Justice
Doncaster (2024)
The Board has identified, on a significant number of occasions, cell bells not being answered. Whilst we welcome the continued scrutiny of cell bell data and attempts by the management team to improve answering times, this issue remains a grave concern for the Board.
Governor / Director
National patient safety alerts(1)
Health investigations(56)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xii)
The Trust and Council should ensure that arrangements are effectively in place for regular monitoring by professionals of the mental state of every service user who is considered to be at risk of relapse.
london
An independent investigation into the care and treatment of a … — Rec R4
The Early Intervention in Psychosis team to monitor the risk status and management plans of those individuals whose mental state appears to be deteriorating via a Red Board meeting three times per week. Clarity needed regarding the RAG [red/amber/green] ratings, criteria for each category and what to do and when …
south_east
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 6
If a patient with complex needs and identified risk issues requires a medical assessment, then that should occur promptly.
north_east_yorkshire
Independent investigation: Alan Clarke, Salisbury (2008) — Rec 9
The Trust should: • complete its development of a its Early Warning Trigger tool in a timely manner; • ensure that this device and/or associated protocols, together with relevant training, enable particularly those undertaking emergency assessments to understand and formulate why an individual is repeatedly presenting in crisis; • consider …
south_west
Independent investigation: Simeon Claxton, Petersfield, Hampshire (2004) — Rec Recommendation 7
It is recommended that input from an AOT be considered in all cases where patients with serious mental illness start to disengage. The risk of alienation is probably small compared to the benefits of keeping patients as well as possible. This in turn will reduce risk as these usually increase …
south_east
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Eight
It is recommended that the Trust develops and implements an Objective Structured Clinical Examination (OSCE) framework for the assessment of particular competencies such as observations, medical devices, physical health and medication administration. The further development of Reflective Practice Groups should also be considered.
london
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Four
It is recommended that all transfers of patients should follow a comprehensive protocol that sets out a checklist that is audited on a regular basis to include: Risk analysis and management. Level of Observations. Management Plan. Physical Health. Medication Concordance History. Allocation of Primary Nurse Role. Diagnosis. Health care needs.
london
Independent investigation: Margaret HarrisSharon Harris, Hadlow, Kent (2018) — Rec 4
NHS Kent and Medway Clinical Commissioning Group to ensure that the Trust provides assurance that the Early Intervention in Psychosis team monitors the risk status and management plans of those individuals whose mental state appears to be deteriorating via a Red Board meeting three times per week. Clarity needed regarding …
south_east
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 13
There were missed opportunities in the clinical management of Patient E’s care, including critical tasks not being completed by frontline staff and compliance controls used by management to prioritise a deteriorating patient and assess risk. Mental Health Trust 1, Council 2b and ICB 2 must provide assurance that learning from …
north_east_yorkshire
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 6
At the time of the incident the CMHT did not have a risk stratification system to indicate which patients were at higher risk of deterioration or were at risk of harm to themselves or others. A system which could have supported the team to convey essential information about dynamic risk …
north_east_yorkshire
Independent investigation: John Rees, Pen Y Graig, Rhondda (2020) — Rec 3
There was merit in some of Mr P ’s challenges [Mr P is Ann’s father] concerning Ann’s inpatient and outpatient care and treatment. On many occasions he had sought to bring Ann’s deteriorating mental health to the attention of professionals. He was comforted by glimpses of her progress but conflict …
wales
Report of a review in respect of: The provision of … — Rec 5
In relation to patient assessments, Betsi Cadwaladr University Health Board should ensure that: a. Staff compliance with their standard for timely senior clinician reviews and physical examinations demonstrating continued compliance. b. In line with their own guidance, all patients are subject to urine drug screening within 2 hours of admission.
wales
Report of a review in respect of: The provision of … — Rec 2
Betsi Cadwaladr University Health Board to provide an update regarding progress made by the Clinical Programme Group (CPG) in agreeing a standard for timely senior clinician reviews and physical examinations. Compliance with these agreed timescales should be monitored.
wales
Independent investigation: Derek Brotherton, Bradford (2004) — Rec 1
Communication with the RMO (paragraph 93). This builds on recommendation 10 of the internal review (see Section 9 of this report). To ensure that the RMO is informed of any significant changes in circumstances or a patient’s condition, an audit should be conducted on at least an annual basis of …
north_east_yorkshire
William Mead – Root Cause Analysis Investigation Report — Rec f)
That NHS England approaches the CDOP SW to discuss how many cases have been identified involving deaths and the possible reluctance of GPs to prescribe antibiotics.
south_west
William Mead – Root Cause Analysis Investigation Report — Rec e)
That NHS England Medical Director Office and the UK Sepsis Trust work actively together, with the input of experts and parents in the SW, on the development of national guidance to parents and GPs regarding childhood sepsis, using the SW as the initial pilot site.
south_west
William Mead – Root Cause Analysis Investigation Report — Rec b)
That a SW initiative is developed urgently for the dissemination of information to parents and GPs on sepsis recognition as a pilot for the national work as per 14.1[e] above.
south_west
Multi-agency systems review to identify the learning following five homicides … — Rec 5
HCP assessments should include clarity on the threshold for fitness to detain regarding mental health, and what mental health presentation changes would indicate that a new medical assessment was required and could be requested. Police Healthcare Provider should provide clarity on threshold for fitness to detain and be evident in …
south_west
Accepted
*Mental health homicide investigation legacy report into the care and … — Rec Recommendation One
The Trust will ensure that all clinical policies and procedures are amended to instruct clinicians of the importance of providing a differential diagnosis where indicated as clinically appropriate. These amendments will also include instructions as to the importance of providing a clear formulation and the guidance for doing so.
Mr X This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust
south_east
Assurance Review: Trust recommendations — Rec 24
Standard operating policies and procedures The Trust must ensure the following are up-to-date and subject to regular audit: • the identification and management of Urosepsis and obstructed kidneys; • the identification and management of sepsis and the deteriorating patient; • the management and registration of stents; • handover of patients …
north_west
An independent mental health homicide investigation into the care and … — Rec 12
AWP should carry out a review of how the assessment and recovery team undertakes and maintains physical health monitoring of patients who have complex mental health and physical health issues.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent investigation into the care and treatment of a … — Rec 7a
A quality standard regarding the recording, timely assessment and documented outcome of a formal mental state assessment when sought by a CAMHS nonmedical practitioner should be specified.
south_east
This Independent Investigation into concerns and issues raised relating to … — Rec 20
The Trust should ensure that all staff involved in the care of deteriorating patients receive appropriate training and adhere to national guidance and best practice, ensuring timely recognition, escalation, and management of acutely unwell patients.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Investigation Report into the NHS Care provided to the late … — Rec 6.5
NHS 111 should review their diagnostic software to ensure it is sufficiently robust to detect atypical presentations of medical conditions.
south_east
Independent investigation into the care and treatment of patient M … — Rec 91
If the person fails to respond, or their condition is deteriorating, they will need to be in an environment where their safety can be maintained. On assessment, this may be a place with heightened levels of observation within the prison, or transfer to hospital may be necessary.
east_of_england
An independent review into the care and treatment given to … — Rec 13
One of the couple had been under the care of Trust services for more than 40 years and there was a pervasive belief among staff and teams that they ‘knew’ them. Even when mentally stable, the service user experienced delusional beliefs. This investigation identified that staff were not able to …
north_east_yorkshire
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 4
Enhance PEWS training, with clear escalation pathways.
north_east_yorkshire
An independent investigation into the NHS care and treatment of … — Rec 2
EPUT must ensure the community mental health teams have a structure and systems for responding to relapse or increase in risks, such as a clinical ‘traffic light’ rating tool.
east_of_england
An independent investigation into the care and treatment of patient … — Rec 13
There were missed opportunities in the clinical management of Patient E’s care, including critical tasks not being completed by frontline staff and compliance controls used by management to prioritise a deteriorating patient and assess risk. Mental Health Trust 1, Council 2b and ICB 2 must provide assurance that learning from …
north_east_yorkshire
Independent investigation: Joseph Day, Folkestone (2001) — Rec 22
Rethink should ensure that its staff are trained to identify and respond to early warning signs of deteriorating mental health or escalating risk in residents. This should include clear protocols for seeking advice from statutory mental health services and for initiating emergency responses when necessary.
south_east
Independent investigation: Simeon Claxton, Petersfield, Hampshire (2004) — Rec Recommendation 5
It is recommended that all professionals be made aware of the finer points of assessing long term patients under the Act in order to prevent serious relapse.
south_east
Independent investigation: Ms B, Cheltenham (2008) — Rec 6
The Trust should develop a process for ensuring that diagnostic reviews take place for patients with long standing histories, multiple diagnoses and who have been taking a variety of medications, who are not responding to treatment, and establish processes for monitoring compliance with this.
south_west
Independent investigation: Lee Johnson, Newcastle (2003) — Rec 6
Following the risk assessment of a patient where there is concern that there may be a deterioration in mental wellbeing there should be explicit communication of this to the other members of the team.
north_east_yorkshire
Independent investigation: Leanne Unsworth, Burnley (2019) — Rec 1
The Trust should ensure that all service users receive a robust and comprehensive diagnostic process that is regularly reviewed and updated in the light of any changes in presentation. This should include a differential diagnosis and diagnostic formulation that is clearly documented in the clinical record.
north_west
Independent investigation: Karen Welsh, Cardiff (2010) — Rec 3.9
The Health Board should ensure that welfare checks for patients on home leave and have not returned to the ward by the expected time and date are carried out with urgency according to the level of risk presented by the patient.
wales
Independent investigation: Jill Louis Nevitt, Oswestry (2010) — Rec Recommendation One
The Trust will ensure that all operational policy documentation provides clear instruction about NICE guidance in relation to the intervals of time that should be allowed to elapse between initial contact/diagnosis and follow up in the case of depression.
midlands
Independent investigation: Douglas Scott, Manor Park (2007) — Rec 1
East London Foundation NHS Trust must ensure that all mental health teams using a Traffic Light System for clinical management purposes, rather than resource management, audit the system on an agreed periodic basis to provide assurance that it is working as intended and to the expected standard of reliability. With …
london
Independent investigation: Brian Dodd, Prestatyn (2003) — Rec a)
That MHRTs (prior to any Legislative amendment) exercise their powers to ensure that problems are addressed at an early date when they are made aware that they exist, or may occur.
wales
Investigation Report into the NHS Care provided to the late … — Rec 6.2
The Trust 5 clinical IT system is modified to enable face to face as a default response after two previous contacts for the same condition, which has to be consciously over-ruled by the assessing clinician.
south_east
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 1
Improve recognition of documentation of differential diagnosis
north_east_yorkshire
An independent investigation into the care and treatment of patient … — Rec 6
At the time of the incident the CMHT did not have a risk stratification system to indicate which patients were at higher risk of deterioration or were at risk of harm to themselves or others. A system which could have supported the team to convey essential information about dynamic risk …
north_east_yorkshire
An independent care pathway review of a young person: Published … — Rec 4
NHS England Specialised Commissioning must share the learning from this case across all regions to ensure a multi-agency systemic approach to complex cases sufficiently early in the patient’s pathway.
london
An independent care pathway review of a young person: Published … — Rec 1
NHS England should introduce a framework (perhaps linked to the CETR process where appropriate) which enables early identification of highly complex adolescent patients in order to facilitate the development of bespoke packages of care in a timely and patient centred fashion. The framework should also allow issues to escalated to …
london
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 32
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients admitted to hospital under the Mental Health Act 1983 have their previous medical notes obtained and reviewed in a timely manner, and that any delays are fully documented and investigated.
midlands
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 24
Where a patient is consistently not eating the food provided by the hospital, this should also be reported as a significant feature of the patient’s presentation and a therapeutic strategy should be devised to address this difficulty
london
Independent investigation: Doreen Griggs, Wisbech, Cambs (2004) — Rec 6
The West Norfolk Primary Care Trust1 should review its training for nursing staff regarding the care of physical health observations of aroused and/or intoxicated patients, particularly those who have received significant doses of prescribed medication.
east_of_england
Independent investigation: Donald Fletcher, Camden (2007) — Rec R2
The trust should fully implement its recommendation 16 for each AOT and ensure that this is a regular part of teamwork. The recommendation states: “AOT to reflect on their operational policy to ensure that thresholds for action are not affected by high tolerance levels. Consideration should be given to external …
london
Independent investigation: Camille Remy (pregnant), Hackney (2006) — Rec R21
North East London Mental Health Foundation Trust should ensure that medical staff carry outa physicalexamination on patients as part of the admission procedure.
london
Independent review of the care and treatment received by JW … — Rec R1
All agencies involved in this investigation should ensure that they have an appropriate plan in place to identify an individual’s serious escalating behaviour at an early stage to enable effective multi-agency oversight and co-ordination. The Safeguarding Adult Board, who have responsibility for holding statutory partners to account, should ensure that …
south_west
Independent investigation into the care and treatment of Patient L: … — Rec 7
The process of risk assessment must enable the classification of riskiness of service users across a range of indicators using an approach that supports the maintenance of team focus on clients who do not meet classical high-risk criteria A traffic light system is one approach to achieving the above. However, …
Sheffield Health and Social Care NHS Foundation Trust
north_east_yorkshire
Scottish Fatal Accident Inquiries(6)
Chloe McIver
The Health Board, therefore, should review its procedures in this regard. This dichotomy of view between a Consultant Paediatrician and the Director of Nursing must be resolved and the appropriate protocol put in place. (c)It was clear from the evidence at the Inquiry that the midwives were not certain as to how they instigated the transfer of a sick baby …
Nov 2005
Anne Denise Clegg or Hefferman
All ERU patients should have the same nursing and medical team responsible for their care;
Jun 2007
Caroline McCall
[98] The evidence in this case suggests that something needs to be done to improve the rate of detection of aortic dissection in expectant mothers. If it has not already done so it respectfully seems to me, that the Greater Glasgow and Clyde Health Board should initiate discussions with the appropriate Medical Authorities, designed to ensure that the issue of …
Mar 2014
WIlliam Harrison
1. Steps should be taken to highlight to junior medical and nursing staff the need to escalate the assessment of patients who have a National Early Warning Score (“NEWS”) in excess of 7 in terms of the NEWS checklist. 2. Consideration should be given to revising the guidance on significant adverse events to further emphasise the importance of establishing the …
Jan 2021
Kyle Robert Brown
However given the important fact here that Miss Thomson in her call clearly indicated that the rash was of a bruising nature, that is to say involving comparatively large areas, rather than small spots, and given Dr Freeman’s evidence that concerned callers were likely to speak of bruises rather than rashes if that is what they looked like, I think …
Oct 2007
Alexander Irvine
In terms of section 26(1)(b), I recommend: 1. That the present system of self-certification of fitness to drive after the age of 70 years be changed as a matter of priority, by limiting self-certification of fitness to drive only to applications before the age of 80 years. Application for renewal should continue to be required every three years, from the …
Oct 2024
Other
3 recs
Article 2 learning points(1)
Independent reviews(23)
Mental Health Taskforce 2016 — Rec 19
NHS England should undertake work to define a quantified national reduction in premature mortality among people with severe mental illness, and an operational plan to begin achieving it from 2017/18. NHS England should also lead work to ensure that by 2020/21, 280,000 more people living with severe mental illness have …
Health & Social Care
Tickell Review of the EYFS — Rec 23
I recommend that, as part of the review of the Development Matters guidance, the Government develops an additional column setting out clearly the key milestones of development for children aged under 24 months.
Education
Wessely Review — Rec 114
Initial Reviews should take place within five days of emergency admission (or three days if it is to adult facility) and at a minimum of four-to-six weekly intervals after that.
Health & Social Care
Accepted
Wessely Review — Rec 94
A patient's physical health should be monitored, so that physical illness and conditions (e.g. diabetes and asthma) can be identified and treated.
Health & Social Care
Accepted
Darzi Review — Rec 11
Care for cardiovascular conditions is going in the wrong direction. Once adjusted for age, the cardiovascular disease mortality rate for people aged under 75 dropped significantly between 2001 and 2010. But improvements have stalled since then and the mortality rate started rising again during the Covid-19 pandemic. Rapid access to …
Health & Social Care
Darzi Review — Rec 10
Cancer care still lags behind other countries. While survival rates at 1-year, 5-years and 10-years have all improved, the rate of improvement slowed substantially during the 2010s. The UK has appreciably higher cancer mortality rates than other countries. No progress whatsoever was made in diagnosing cancer at stage I and …
Health & Social Care
Greenaway Shape of Training Review — Rec 12
All doctors must be able to manage acutely ill patients with multiple co-morbidities within their broad specialty areas, and most doctors will continue to maintain these skills in their future careers.
Health & Social Care
Francis Inquiry (Mid Staffs 2010) — Rec 13
All wards admitting elderly, acutely ill patients in significant numbers should have multidisciplinary meetings, with consultant medical input, on a weekly basis. The level of specialist elderly care medical input should also be reviewed, and all nursing staff (including healthcare assistants) should have training in the diagnosis and management of …
Health & Social Care
O'Neill AMR Review — Rec 5
Promote new, rapid diagnostics to cut unnecessary use of antibiotics 5.1 In high-income countries, governments, regulators and other health system leaders to support the uptake and use of rapid point-of-care diagnostics in primary and secondary care. Incentives should be considered in high-income countries to facilitate the mandatory use of such …
Health & Social Care
Tickell Review of the EYFS — Rec 24
I recommend that the EYFS is made more explicit about the different approaches to assessment that practitioners may wish to consider for those children with special educational needs.
Education
Tickell Review of the EYFS — Rec 19
Practitioners have told me how helpful they find the non-statutory guidance on ongoing, formative assessment, Development Matters, in tracking children's learning and development from birth through to reception. I therefore recommend that this is retained but is reviewed and slimmed-down, and is aligned with my proposed new areas of learning.
Education
Angiolini Review — Rec 1
Police practice must recognise that all restraint can cause death. Recognition must be given to the wider dangers posed by restraining someone in a heightened physical and mental state, where the system can become rapidly and fatally overloaded. Position is not always the determining feature. As great a danger can …
Policing & Security
Accepted
Ockenden Review — Rec 12
Postnatal care. Essential action: Trusts must ensure that women readmitted to a postnatal ward and all unwell postnatal women have timely consultant review. Postnatal wards must be adequately staffed at all times. • All trusts must develop a system to ensure consultant review of all postnatal readmissions, and unwell postnatal …
Health & Social Care
Accepted
Ockenden Review — Rec 10
Labour and birth. Essential action: Women who choose birth outside a hospital setting must receive accurate advice with regards to transfer times to an obstetric unit should this be necessary. Centralised CTG monitoring systems should be mandatory in obstetric units. • All women must undergo a full clinical assessment when …
Health & Social Care
Accepted
Tickell Review of the EYFS — Rec 26
I recommend that guidance sets out that assessment should be based primarily on the observation of daily activities that illustrate children's embedded learning.
Education
Tickell Review of the EYFS — Rec 22
I recommend that for each early learning goal a simple scale is established. This should define what emerging, expecting and exceeding means for each early learning goal. I also recommend that the level of exceeding the early learning goals is set to be consistent with expectations in the current National …
Education
Tickell Review of the EYFS — Rec 21
I recommend that the Government adopt the reduced set of early learning goals to provide a framework which defines the expected level of children's development by the end of reception year.
Education
Tickell Review of the EYFS — Rec 20
[I] recommend no changes to the EYFS requirements on formative assessment…[but] that the EYFS explicitly states that paperwork should be kept to the absolute minimum required to promote children's successful learning and development.
Education
Tickell Review of the EYFS — Rec 15
I recommend strongly that the Government works with experts and services to test the feasibility of a single integrated review at age 2 to 2½.
Education
East Kent Maternity Review — Rec 1
The prompt establishment of a Task Force with appropriate membership to drive the introduction of valid maternity and neonatal outcome measures capable of differentiating signals among noise to display significant trends and outliers, for mandatory national use.
Health & Social Care
Angiolini Review — Rec 2
There should be mandatory and accredited national training for police officers in restraint techniques, including de-escalation and supervision of vital signs during restraint, with appropriate refresher training for officers. There should be national consistency in approaches to the use of force.
Policing & Security
Accepted
Ockenden Review — Rec 9
Preterm birth. Essential action: The LMNS, commissioners and trusts must work collaboratively to ensure systems are in place for the management of women at high risk of preterm birth. Trusts must implement NHS Saving Babies Lives Version 2 (2019). • Senior clinicians must be involved in counselling women at high …
Health & Social Care
Accepted
Tickell Review of the EYFS — Rec 16
I recommend that the Government investigate urgently how the development of children's English language skills can be effectively supported and assessed.
Education
PHSO casework decisions(746)
P-001414 — Mid Yorkshire Hospitals NHS Trust
Mr A complained the Trust missed signs of a gastrointestinal bleed in his brother, Mr R, and inappropriately tried to discharge him despite his deteriorating health, leading to his death.
NHS in England
Partly Upheld
Jun 2022
P-003342 — Northern Care Alliance NHS Foundation Trust
Miss A complained doctors failed to inform her of lung nodules found in a 2021 CT scan until 2024, by which time her cancer was incurable, alleging it could have been treatable earlier.
NHS in England
Feb 2025
P-003595 — North Cumbria Integrated Care NHS Foundation Trust
Mr A complained North Cumbria Integrated Care NHS Foundation Trust failed to quickly identify his mother's serious condition in ED, delayed moving her to critical care, and lost blood tests, impacting her cognitive function.
NHS in England
Not Upheld
Jun 2025
P-003649 — Cheshire and Wirral Partnership NHS Foundation Trust
Mrs K complained the Trust dismissed her mother's hip pain as 'attention seeking', missing a fractured hip diagnosis and treatment, leading to suffering and immobility.
NHS in England
Jul 2025
P-004128 — University College London Hospitals NHS Foundation Trust
Prof. A complained the Trust failed to adequately monitor his brother's skin for necrotising fasciitis, perform timely debridement, or monitor for infection spread post-surgery.
NHS in England
Partly Upheld
Oct 2025
P-004243 — The Queen Elizabeth Hospital King's Lynn NHS Foundation …
Mrs B complained her father's care was poor, citing delayed doctor review after a fall, neglected catheterisation, and slow medical intervention, contributing to his death.
NHS in England
Partly Upheld
Oct 2025
P-004299 — Surrey and Sussex Healthcare NHS Trust
Mr C complained that Ms M's CT scans showing cancer were misread or not acted upon, leading to a significant delay in diagnosis and treatment.
NHS in England
Partly Upheld
Nov 2025
P-001119 — University Hospitals of North Midlands NHS Trust
Mr E complained the Trust failed to act on his symptoms and refer him for investigations, delaying his stage 4 Hodgkin's lymphoma diagnosis and treatment, and demonstrating poor communication.
NHS in England
Partly Upheld
Sep 2021
P-001111 — Gateshead Health NHS Foundation Trust
Mr T complained ED staff inadequately investigated his dislocated toe and orthopaedic care was severely delayed for a year, causing deterioration, infection, and toe amputation.
NHS in England
Partly Upheld
Sep 2021
P-001265 — Croydon Health Services NHS Trust
Ms L complained doctors failed to identify and treat infections and sepsis in her father, leading to an avoidable death. She disputed the Trust's lymphoma diagnosis and suspected a cover-up.
NHS in England
Partly Upheld
Jan 2022
P-001427 — An urgent care centre in the Stoke-on-Trent area
Mrs I complained a doctor failed to appropriately triage her husband during a 111 call and check his oxygen levels, leading to delayed treatment and his death.
NHS in England
Partly Upheld
May 2022
P-001391 — London Ambulance Service NHS Trust
Ms R complained the London Ambulance Service failed to recognise her critically ill father, causing a significant delay in hospitalisation and denying him recovery, along with delayed and insufficient complaint responses.
NHS in England
May 2022
P-001436 — North Tees and Hartlepool NHS Foundation Trust
Mrs L complained the Trust misdiagnosed her stroke as a migraine, prescribed inappropriate medication (Sumatriptan), and failed to consider alternative medication, leading to health deterioration and distress.
NHS in England
Jun 2022
P-001466 — Mid and South Essex NHS Foundation Trust
Mr O complained the Trust failed to appropriately diagnose his heart problems in April-May 2018, despite his symptoms, forcing him to seek expensive private care.
NHS in England
Partly Upheld
Jul 2022
P-001497 — University Hospitals Of Leicester NHS Trust
Mr U complained doctors and nurses missed a red flag sign of chest pain in his mother and failed to conduct further investigations, leading to her death from a heart attack.
NHS in England
Upheld
Aug 2022
P-001634 — George Eliot Hospital NHS Trust
The complainant alleged the Trust delayed her husband's admission, endoscopy, and chemotherapy, and failed to monitor his condition, causing his cancer to spread and denying him surgery.
NHS in England
Oct 2022
P-001606 — A medical practice in the Plymouth area
Mr O complained about a delay in diagnosing asbestosis and not receiving priority treatment due to his veteran status, despite earlier signs of asbestos exposure.
NHS in England
Nov 2022
P-001618 — A medical practice in the Doncaster area
Mr C complained the Practice failed to correctly refer him for the right tests, leading to his kidney being removed, which he believes could have been avoided with earlier, correct testing.
NHS in England
Nov 2022
P-001692 — A medical practice in the Calderdale area
Ms X complained the Practice arranged a physiotherapist for Ms Z instead of a GP for her symptoms, failing to identify signs of a heart attack, which she later died from.
NHS in England
Nov 2022
P-001599 — A medical practice in the Colchester area
Mrs U complained that a medical practice, a hospital trust, and an ambulance trust missed signs of organ failure and peripheral artery disease, causing Mrs A's death.
NHS in England
Nov 2022
P-001608 — A medical practice in the Havering area
Miss L complained the Practice failed to refer Mr L for crucial tests (X-ray, MRI) and offered insufficient face-to-face appointments, delaying his lung cancer diagnosis.
NHS in England
Nov 2022
P-001672 — A medical practice in the Staffordshire area
Mr R complained the Practice failed to detect signs of DVT and pneumonia risk in July 2021, and about delays and inadequate responses to his subsequent complaint.
NHS in England
Dec 2022
P-001674 — A medical practice in the Hampshire area
The Practice failed to recognise serious symptoms and diagnose giant cell arteritis, leading to vision loss and permanent damage to the optic nerve.
NHS in England
Dec 2022
P-001978 — Mid Yorkshire Hospitals NHS Trust
Doctors failed to identify stroke signs, provide appropriate treatment, and keep the family informed, denying her husband a chance of survival and preventing final goodbyes.
NHS in England
Upheld
Dec 2022
P-002294 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs A complained the Trust's delayed diagnosis, poor tracheostomy management, and inappropriate removal of the tube led to her mother's death and caused further distress.
NHS in England
Upheld
Sep 2023
P-002398 — A practice in the Warrington area
Mrs U complained her husband's GP practice failed to send him to hospital after examining his symptoms in July 2022, leading to a delay before his eventual admission and death.
NHS in England
Jan 2024
P-002599 — A practice in the Wigan area
Mr E complained the Practice failed to assess his father's severe pain and weight loss, leading to a delayed cancer diagnosis and death. Complaint handling was also poor.
NHS in England
Upheld
May 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-002742 — A practice in the Lincolnshire area
The Practice allegedly missed opportunities to investigate Mr O's symptoms, delaying cancer diagnosis, and failed to provide face-to-face GP appointments, impacting his health.
NHS in England
Upheld
Jul 2024
P-002805 — East of England Ambulance Service NHS Trust
Mr G complained about multiple missed opportunities to diagnose heart problems, including an unacted-on X-ray and a failed ambulance attendance, leading to a delayed heart failure diagnosis.
NHS in England
Jul 2024
P-002817 — A practice in the East Riding of Yorkshire …
Miss E complained the Practice failed to diagnose Mr N's chest pain as a heart problem and refer him for urgent treatment, leading to a preventable heart attack and death.
NHS in England
Not Upheld
Jul 2024
P-002851 — A practice in the Birmingham area
Dr F complained that emergency department and a GP failed to identify his son's sepsis, misdiagnosing him, which tragically led to his son's death.
NHS in England
Aug 2024
P-002983 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs H complained the Trust failed to timely diagnose her husband's cancer, poorly communicated his condition, did not prevent his escape, and inadequately informed her about tumour lysis syndrome.
NHS in England
Sep 2024
P-003007 — Lewisham and Greenwich NHS Trust
The Trust failed to communicate risks considering her memory, did not X-ray post-op, and delayed diagnosing a displaced femur, causing prolonged pain and long-term mobility issues.
NHS in England
Upheld
Sep 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-003081 — A practice in the Rushcliffe area
Mr I and Mrs Y complained the Practice failed to assess their mother's stroke symptoms, delaying care. They also alleged poor end-of-life care, including inappropriate pain relief administration and a lack of compassion from the District Nursing Team.
NHS in England
Oct 2024
P-003090 — University Hospitals of North Midlands NHS Trust
Mrs M complained the Trust did not appropriately act on her mother's chest pains or blood test results, delayed an ECG, inappropriately administered medication, and ignored her call bell, resulting in her avoidable death.
NHS in England
Upheld
Oct 2024
P-003048 — Worcestershire Acute Hospitals NHS Trust
Miss Y complained the Trust delayed her mother's emergency admission, didn't take her condition seriously, communicated poorly, and failed to provide adequate pain relief or review an X-ray before her mother's death.
NHS in England
Oct 2024
P-003041 — A practice in the Gateshead area
Mrs L complained the Practice did not take her concerns about increasing pain and growth of a lipoma seriously. This allegedly led to a delayed sarcoma diagnosis, requiring more extensive surgery and ongoing pain.
NHS in England
Oct 2024
P-003154 — Milton Keynes University Hospital NHS Foundation Trust
Miss A complained the Trust misdiagnosed her appendicitis, discharged her without proper treatment or pain relief, and delayed care upon her return to A&E, causing unnecessary pain and distress.
NHS in England
Partly Upheld
Nov 2024
P-003112 — A practice in the Solihull area
Mr A complained the Practice failed to diagnose deep vein thrombosis (DVT) in his leg, which progressed to a pulmonary embolism, causing pain, hospitalisation, and ongoing issues.
NHS in England
Nov 2024
P-003113 — Walsall Healthcare NHS Trust
Mr V complained the Trust failed to assess, diagnose cellulitis and sepsis, and dismissed his symptoms, including heart palpitations, leading to serious health complications.
NHS in England
Nov 2024
P-003129 — Croydon Health Services NHS Trust
Ms G complained the Trust failed to recognise the severity of B's illness, took too long to treat and escalate care, and did not listen to her concerns about sepsis.
NHS in England
Nov 2024
P-003145 — Mid Yorkshire Teaching NHS Trust
Staff failed to sufficiently investigate a suspected fracture, missing a hip fracture, and made inappropriate discharge decisions, leading to pain, a collapse, and premature death.
NHS in England
Upheld
Nov 2024
P-003176 — Croydon Health Services NHS Trust
The Trust failed to recognise her mother's serious condition, provide appropriate care, keep the family informed, and gave a wrong diagnosis, leading to her mother's death alone.
NHS in England
Nov 2024
P-003304 — The Hillingdon Hospitals NHS Foundation Trust
Mr V complained The Hillingdon Hospitals NHS Foundation Trust delayed his father's admission and CT scans despite clear stroke symptoms, believing this affected his chance of survival.
NHS in England
Not Upheld
Jan 2025
P-003306 — Mid Yorkshire Teaching NHS Trust
Mrs U complained the Trust failed to diagnose her husband’s lung cancer from a chest X-ray in January 2022 and again from a scan in March, leading to delayed diagnosis and treatment.
NHS in England
Partly Upheld
Jan 2025
P-003553 — A practice in the Cornwall area
Mr and Miss G complained the Practice failed to provide their mother face-to-face care, antibiotics, or safety netting for her cough, alleging this led to her death.
NHS in England
May 2025
P-003547 — A practice in the Telford and Wrekin area
Mrs L complained an Advanced Nurse Practitioner inadequately examined her and dismissed symptoms, delaying her cancer diagnosis and treatment by six weeks.
NHS in England
May 2025
P-003552 — A practice in the North Kesteven area
Mrs P complained the Practice failed to investigate her husband's deteriorating condition and prescribed naproxen without blood tests, potentially causing gastrointestinal bleeding and missing treatment opportunities.
NHS in England
May 2025
LGO / SPSO decisions(332)
NIPSO-201916987 — Western Health and Social Care Trust
We found that a patient who was showing signs of sepsis should have been referred to a senior clinician in Altnagelvin Hospital. We asked for the Trust to apologise to the complainant, and that it raises awareness of sepsis among junior doctors.
NIPSO (NI Public Service…
Health & Social Care
Jul 2022
NIPSO-202002199 — Northern Health and Social Care Trust
We upheld a complaint from a woman who said that her late mother should not have been discharged from Antrim Area Hospital.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
23-021-216 — Suffolk County Council
Summary: The complainant (Mrs X) said the Council had failed to comply with the statutory timescales for an Education Health and Care needs assessment for her son (Y) and had failed within its communication with her. We found fault in the Council’s delays and communication. This fault caused Y and …
LGO (Local Government & …
Education
Upheld
Jul 2024
23-018-725 — Suffolk County Council
Summary: Mrs D complained the Council failed to provide the provision in Mr E's Education, Health and Care Plan. We find the Council was at fault for its delays in putting the provision in place. The Council has agreed to our recommendation to address the injustice caused by fault.
LGO (Local Government & …
Education
Upheld
Jul 2024
23-004-534 — Barnsley Metropolitan Borough Council
Summary: Mrs X complains the Council have not dealt with her son Y’s Special Educational Needs (SEN) properly. The Council did not complete an annual review properly, delayed responding to Mrs X’s complaint and did not fully complete recommendations arising from its complaint response. Mrs X had her right of …
LGO (Local Government & …
Education
Upheld
Jul 2024
23-008-993 — Kent County Council
Summary: Mrs X complains the Council failed to provide special educational needs provision for her child D in line with their Education, Health, and Care Plan. There was fault by the Council which caused D to miss provision and caused financial loss to Mrs X because she paid for some …
LGO (Local Government & …
Education
Upheld
Jul 2024
23-015-243 — Thurrock Council
Summary: We have found fault with the Council for how it handled Mrs X’s son (Y) post-16 education transfer. The Council delayed the Education Health Care Plan review, did not consider its Section 19 duty, and did not deliver alternative education provision while Y was waiting for a suitable post-16 …
LGO (Local Government & …
Education
Upheld
Jul 2024
NIPSO-investigation-complaint-medical-staffs-slow-response-led-patient — Northern Health and Social Care TrustBelfast Health and …
Ombudsman finds that man’s ‘red-eye’ should have been monitored more closely, and that an earlier diagnosis would have improved the chances of his vision being retained.
NIPSO (NI Public Service…
Health & Social Care
Oct 2018
NIPSO-proper-care-and-treatment-patient-trust-may-have-improved-her — Northern Health and Social Care Trust
An investigation has found that the Northern Health and Social Care Trust failed to provide adequate care and treatment to a patient who died of multiple organ failure in the Causeway Hospital, Coleraine on 26 September 2015.
NIPSO (NI Public Service…
Health & Social Care
Jul 2019
NIPSO-16809 — Western Health and Social Care Trust
The Public Services Ombudsman has upheld a complaint from a woman who waited 20 months to have a carer's assessment carried out by the Western Health and Social Care Trust.
NIPSO (NI Public Service…
Health & Social Care
Oct 2019
NIPSO-22298 — 3fivetwo Healthcare Group
Our investigation found that 3FiveTwo’s treatment of a patient was appropriate, but that errors led to a delay in her treatment.
NIPSO (NI Public Service…
Health & Social Care
Jul 2021
NIPSO-201917009 — Southern Health and Social Care Trust
A woman who feared she had cancer complained that the Southern Health Trust should have operated to remove her womb. Our investigation found no failures by the Trust.
NIPSO (NI Public Service…
Health & Social Care
Jul 2022
NIPSO-202000111 — Hillsborough Medical Practice
Our report criticised a GP practice after a delay in providing a woman’s medication caused her unnecessary discomfort.
NIPSO (NI Public Service…
Health & Social Care
Feb 2023
NIPSO-202000460 — Belfast Health and Social Care Trust
A patient was in pain for longer than necessary because of delays by the Belfast Trust to obtain the results of a private MRI scan.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Feb 2023
NIPSO-202000307 — Belfast Health and Social Care Trust
The Belfast Health Trust has apologised to a man after our investigation found failures in the care of his late wife.
NIPSO (NI Public Service…
Health & Social Care
Mar 2023
NIPSO-202002854 — GP
A patient was prescribed diazepam after he complained to his GP about feeling unwell. We asked the surgery to apologise after he was later found to have suffered five strokes in the space of a week.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Sep 2024
NIPSO-202005762 — GP
A woman claimed that if her late husband’s weight loss been investigated properly his cancer may have been detected sooner. We found it was a ‘significant failure in care and treatment’ that his GP didn’t send him for further diagnostic treatment.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2025
21-007-956 — London Borough of Lewisham
Summary: Mr X complained that the Council failed to provide his disabled son, Mr P, with an educational placement for up to two years. He says this has caused Mr X and his wife, Mrs X an injustice as the family have had to care and educate Mr P themselves. …
LGO (Local Government & …
Education
Upheld
Feb 2022
21-006-581 — London Borough of Richmond upon Thames
Summary: Mrs D complains about the Council’s handling of her son F’s Education, Health and Care plan. She says it did not adhere to the Special Educational Needs and Disabilities Code of Practice. Mrs D says she had to pay for privately arranged therapy and F missed education due to …
LGO (Local Government & …
Education
Upheld
Feb 2022
21-004-641 — Kent County Council
Summary: We upheld a complaint about a delay in issuing an Education, Health and Care Plan. The delay caused avoidable distress, a delay in appeal rights and a loss of education provision for Y who has autism. The Council will apologise, make payments and take action described in this statement.
LGO (Local Government & …
Education
Upheld
Feb 2022
21-010-627 — City of Bradford Metropolitan District Council
Summary: Mr A complains about poor care provided by Mrs X’s care provider. He says the carer left her when she was in a diabetic coma and did not contact the family to let them know she was will. He also complains the care provider failed to contact the family …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
22-001-500 — Birmingham City Council
Summary: Mr X complained about delays in carrying out bathroom adaptations and about the quality of the work. The Council delayed allocating a contractor to carry out remedial work and this was fault for which it has already apologised. This was an appropriate remedy. Further delays in completing the works …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
22-002-090b — Northumbria Healthcare NHS Foundation Trust (22 002 090b)
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Health
Upheld
Dec 2022
23-003-322 — Suffolk County Council
Summary: Mrs X complains about the Council’s handling of her child’s, Child Y, education. The Council was at fault for not ensuring Child Y received all the provision in their Education, Health and Care (EHC) Plan and associated personal budget from February to October 2022. The Council also delayed or …
LGO (Local Government & …
Education
Upheld
Apr 2024
23-020-295 — Essex County Council
Summary: We will not investigate Miss X’s complaint about delays in the Education Health and Care Plan process. This is because the Council has agreed to apologise to Miss X and pay her £100 per month for the delay. We consider this an appropriate remedy and further investigation is therefore …
LGO (Local Government & …
Education
Upheld
Apr 2024
23-021-238 — Essex County Council
Summary: We upheld Mrs X’s complaint about delays in the Education, Health and Care process regarding her child, Y. The Council has agreed to resolve the complaint early by providing a proportionate remedy for the injustice caused.
LGO (Local Government & …
Education
Upheld
May 2024
23-013-550 — Suffolk County Council
Summary: Mrs X complained that the Council did not complete the review of her child’s education, health and care plan properly or in a timely fashion causing distress, frustration and uncertainty. We found the Council was at fault in failing to comply with statutory timescales. In recognition of the injustice …
LGO (Local Government & …
Education
Upheld
May 2024
23-010-551 — North Yorkshire Council
Summary: The Council accepted fault in that it failed to provide alternative education for the complainant’s child when the College ended the placement. The Council offered a remedy for the injustice which the complainant considered insufficient. We have recommended actions to add to the Council’s remedy, which the Council has …
LGO (Local Government & …
Education
Upheld
May 2024
23-011-518 — Rochdale Metropolitan Borough Council
Summary: Ms Y complained on behalf of Mrs X about the time taken by the Council to complete adaptations to Mrs X’s home. We have found the Council at fault for delaying completing adaptations to Mrs X’s property. As a result, Mrs X has lived in her home without adaptations …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
24-002-333 — Essex County Council
Summary: We will not investigate this complaint about delays in the Education, Health and Care plan process. This is because the Council has agreed to an appropriate remedy for the injustice caused by the delay.
LGO (Local Government & …
Education
Upheld
Jul 2024
23-018-316 — London Borough of Haringey
Summary: Mr X complains the Council delayed dealing with a disabled facility grant. The Council delayed dealing with his application. Mr X suffered delay and avoidable distress. The Council should pay Mr X £500.
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
24-000-087 — Leeds City Council
Summary: Mrs X complained about the significant delays in the education, health and care plan process. We find the Council was at fault. This had a significant impact on Mrs X and her daughter. To remedy this injustice caused by fault the Council has agreed to apologise and make symbolic …
LGO (Local Government & …
Education
Upheld
Sep 2024
23-020-178 — Devon County Council
Summary: Mrs X complained the Council delayed completing her daughter, Y’s Education, Health and Care (EHC) needs assessment in line with statutory timescales. The Council was at fault. It delayed deciding whether to issue Y with an EHC Plan within the statutory timescales, caused by a 19 week delay in …
LGO (Local Government & …
Education
Upheld
Oct 2024
24-006-978 — City of Doncaster Council
Summary: We have upheld this complaint because the Council delayed issuing an Education Health and Care Plan for a child. The Council has agreed to resolve the complaint by making a suitable payment to the complainant to remedy the injustice its delays caused.
LGO (Local Government & …
Education
Upheld
Oct 2024
24-003-787 — Devon County Council
Summary: Mr X complained the Council delayed completing his son Y’s Education, Health and Care (EHC) needs assessment in line with statutory timescales. The Council was at fault because it failed to decide whether to issue Y with an EHC Plan within the statutory timescales, caused by a delay in …
LGO (Local Government & …
Education
Upheld
Oct 2024
24-010-995 — Tameside Metropolitan Borough Council
Summary: Mrs X complained that the Council delayed in its decision to refuse to reassess her son, Y’s, special educational needs, and delayed in issuing an amended Education, Health and Care Plan following an annual review. We found fault on the part of the Council which caused injustice to Mrs …
LGO (Local Government & …
Education
Upheld
Apr 2025
24-016-641a — Dudley Group NHS Foundation Trust (24 016 641a)
Summary: Mr X complained the NHS Trust and the Council moved his father from hospital into a care home that could not meet his needs. Mr X says the failings led to his father suffering an injury which hastened his death. Mr X also complained the Council missed carer’s assessments, …
LGO (Local Government & …
Health
May 2025
24-007-937 — Wirral Metropolitan Borough Council
Summary: We will not investigate this complaint that the Council has failed to address the complainant’s son’s special educational needs and has failed to make alternative educational provision for him. Her complaint about the period before her son’s Education Health and Care Plan was issued is late and there are …
LGO (Local Government & …
Education
Oct 2024
24-000-603 — London Borough of Havering
Summary: Ms X complained that the Council failed to properly consider her request for adaptations to be made to her council property. We cannot investigate the Council’s actions as a registered social landlord. However, we found the Council was at fault for not considering a Disabled Facilities Grant (DFG). We …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
23-020-952 — Broadland District Council
Summary: Mrs X complains the Council was at fault in the way it dealt with her application for a disabled facilities grant causing distress. We found fault because the Council delayed carrying out an assessment by an occupational therapist on Mrs X for her application. The Council has accepted it …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
24-010-997 — Essex County Council
Summary: We will not investigate Miss X’s complaint about delays in the Education Health and Care Plan process. This is because the Council has agreed to apologise to Miss X and pay her £100 per month for the delay. We consider this an appropriate remedy and further investigation is therefore …
LGO (Local Government & …
Education
Upheld
Oct 2024
24-009-706 — Essex County Council
Summary: We will not investigate Ms X’s complaint about delays in the Education Health and Care Plan process. This is because the Council has agreed to apologise to Ms X and pay her £100 per month for the delay. We consider this an appropriate remedy and further investigation is therefore …
LGO (Local Government & …
Education
Upheld
Oct 2024
24-005-108 — Lancashire County Council
Summary: Mrs X complains about delay in the education, health and care plan process for her son. Mrs X says the Council failed to meet statutory timescales and failed to respond to her communications. The Council has agreed to apologise, make a payment to Mrs X and issue a reminder …
LGO (Local Government & …
Education
Upheld
Nov 2024
24-004-296 — Stoke-on-Trent City Council
Summary: We upheld Ms X’s complaint about a failure to secure special educational provision in her child Y’s Education, Health and Care Plan. This caused a loss of educational provision, avoidable frustration, uncertainty and time and trouble. The Council will apologise, provide a copy of the action plan setting out …
LGO (Local Government & …
Education
Upheld
Nov 2024
24-009-611 — Medway Council
Summary: We will not investigate Ms X’s complaint about delay in her child’s Education, Health and Care Plan annual review process. An investigation would be unlikely to lead to a different outcome. Ms X has appealed to the SEND Tribunal about the content of the plan and the Tribunal can …
LGO (Local Government & …
Education
Nov 2024
201800817 — Scottish Ambulance Service
Mrs C complained that the Scottish Ambulance Service (SAS) delayed in sending an ambulance for her husband (Mr A). Mr A's GP requested an ambulance within two hours as Mr A was experiencing vomiting and diarrhoea and was delirious. The ambulance did not arrive until almost eight hours later. SAS …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2019
201808173 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C, a support and advocacy worker, complained on behalf of her client (Miss B). Miss B was concerned that her mother (Mrs A) had been discharged prematurely from Royal Alexandra Hospital. Mrs A had been discharged the day after her admission. Mrs A deteriorated suddenly following her discharge and …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2020
201803709 — Lanarkshire NHS Board
Mr C complained about the care and treatment his mother (Mrs A) received at University Hospital Monklands during her initial admission and subsequent readmission to hospital for treatment for supraglottis with parapharyngeal oedema (infections of the upper airways/throat). We took independent advice from an ear, nose and throat consultant and …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2020
201810154 — Tayside NHS Board
C is the parent of a teenaged adult (A). A was admitted to an acute admissions ward of a mental health unit as an informal patient. The following day, A contacted C from the ward. A told C that they were in possession of razor blades and intended to self-harm. …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2020
NIPSO-18545 — Northern Health and Social Care Trust
The care and treatment provided to a complainant by the Accident & Emergency Department at Causeway Hospital was 'in accordance with good medical practice.'
NIPSO (NI Public Service…
Health & Social Care
Jul 2000
Domestic Homicide Reviews(24)
Bury — recommendation 3
Review the current process for reviewing A&E attendances within health visiting PCFT
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Nuneaton and Bedworth — recommendation 23
George Eliot Hospital puts in place procedures to ensure that correspondence from A&E to GPs is legible and forwarded without delay following presentation of a patient with serious issues such as self-harm, a suicide attempt or abuse.
George Eliot Hospital
George Eliot Hospital
St Helens — recommendation 25.6
The current practice of telephone triage for patients with complex needs to cease and those identified patients be offered face to face appointments.
North West Boroughs Healthcare
North West Boroughs Healthcare …
Telford and Wrekin — recommendation 10
Clearly Identify the reason for a patient seeking medical attention and highlight this to the consulting clinician in case of lack of contact with the patient
The GP Practice
Braintree — recommendation 5.1
That a formal process should be developed by which the police can notify mental health professionals of an individual’s deteriorating mental health where it does not meet the threshold for Section 135/136 of the Mental Health Act 1983 or the Mental Capacity Act 2005. The review reiterates the recommendation made …
Essex Police | EPUT
Essex Police
North Lincolnshire — recommendation 8.13
Follow up screening for IDVAs when depression or suicidal thoughts are disclosed should be considered.
It’s My Right
Leeds — recommendation Recommendation Two
We recommend a practice improvement in relation to the conducting and administration of the PHQ-9. The processes that GPs have in place for the use of PHQ-9s should be reviewed and if necessary amended to ensure that following completion PHQ-9’s are reviewed and any appropriate action is taken.
General Practices | NHS Clinical Commissioning …
Dental Practice Board
Manchester — recommendation 4
That Manchester Community Safety Partnership request Manchester Health and Care Commissioning to address the issues emerging from this DHR, in particular: The findings from the review are shared with Primary Care with the expectation that all presenting needs of patients are considered and that professional curiosity is exercised to …
Manchester Community Safety Partnership | Manchester …
Liverpool — recommendation 8.8.2
Emphasizing the importance of professional curiosity.
GP Practice
Aylesbury Vale — recommendation 14 (SCAS)
SCAS to internally share the learning from this incident, particularly in respect to the missed opportunity of completing a safeguarding referral when presenting circumstances indicate that a person is vulnerable or at risk.
South Central Ambulance Service NHS Trust
South Central Ambulance Service …
Dudley — recommendation Adult Social Care 1
72hr post discharge review to be carried out for all urgent care referrals, to ensure any changes in need or identification of aids and adaptations are confirmed in a timely manner.
Dudley Council Adult Social Care
Doncaster — recommendation 2
To ensure all people waiting for Care Act assessments are contacted on a regular basis to inform risk assessment.
Doncaster Adult Social Care
Enfield — recommendation 5
Staff in Accident and Emergency Departments should receive training about self-harm and self-harm should be included in all local domestic abuse training. (This should ensure that staff have an understanding of unusual self-inflicted injuries (e.g. the victim's facial injury or 'accidental' injuries)
Accident and Emergency Departments
Bristol — recommendation 31
Staff are to be reminded of the importance of recording and to keep all agencies updated of non-engagement and signs of deterioration or withdrawal.
Bournemouth Borough Council – Housing & …
Shropshire — recommendation 8.2a
Ensure all incidents/risks relating to a service user are communicated to their GP within 24 hours.
Shropshire Recovery Partnership (We are with …
East Sussex — recommendation 12
That the council ensures that all work to be carried out because of domestic abuse is carried out as an emergency or within an agreed timescale.
Lewes District Council – Tenancy Services …
North Worcestershire — recommendation 1
Worcester Acute Hospitals NHS Trust to review the number of previous Accident and Emergency Department attendances upon admission of a person and to consider any potential safeguarding concerns.
Worcestershire Acute Hospitals NHS Trust
Worcestershire Acute Hospitals NHS …
New Forest — recommendation 1
The General Practices referred to in this Review, with the support of the CCG and NHS England where appropriate, to ensure that frequent attenders are identified and flagged, and develop of a set of options to be considered when a frequent attender is identified. Options could include the patient seeing …
General Practices | West Hampshire Clinical …
NHS England
Kirklees — recommendation 22
There should be an improvement in the recognition of adults at risk of abuse or neglect when they attend accident and emergency
Calderdale and Huddersfield NHS Foundation Trust
Calderdale and Huddersfield NHS …
Kirklees — recommendation 21
To ensure that all patients are routinely asked about domestic violence and abuse when triaged in accident and emergency departments and that appropriate and proportionate action is taken immediately. Where there is a history of patients leaving the department before being seen, an appropriate triage risk assessment should take place …
Calderdale and Huddersfield NHS Foundation Trust
Calderdale and Huddersfield NHS …
Harrow — recommendation 2
Discuss in Leaders Meetings ward meetings and handovers.
Ealing Hospital
Ealing Hospital NHS Trust
Stoke-on-Trent — recommendation IPCC_R1
That in conjunction with upgrades to their IT system, Staffordshire Police considers operating a process in the Control Room to proactively audit un-resourced incidents and to demonstrate that, where a response has been delayed beyond the target time limit, the incident has been regularly reviewed by a supervisor.
Staffordshire Police
Staffordshire Police
Basildon — recommendation 11.2.1
That Basildon Hospital reviews its flagging alert system to consider domestic abuse.
Basildon Thurrock University Hospital
Basildon and Thurrock University …
Ealing — recommendation 4
WLNHS to develop an ERTE system to ensure individual clinicians and their managers are alerted to any cases where risk assessment are falling out of date and that updates are audited.
West London NHS Trust
West London NHS Trust
DSA service inquiries(2)
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood on 16 November 2020
Maritime
Mar 2022
Service Inquiry into the fatal collapse of a service person while undertaking a run in Sennelager, Germany, on 16 January 2023
The Service Inquiry report into the fatal collapse of a service person while undertaking a run in Sennelager, Germany, on 16 January 2023.
Other
Jul 2024
CQC enforcement actions(16)
Conditions Imposed: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission imposed urgent conditions on Shrewsbury and Telford Hospital NHS Trust's registration following inspections of its maternity and emergency departments. Inspections highlighted concerns regarding reduced foetal movements guidelines in maternity services and the treatment and recognition of …
Oct 2018
Criminal Prosecution: The Dudley Group NHS Foundation Trust
The trust pleaded guilty to failing to provide safe care and treatment to two patients who died of sepsis-related causes in 2018, Natalie Billingham and Kaysie-Jane Bland. The court identified failings in the recognition and treatment of sepsis.
Nov 2021
£2533332
Warning Notice: East Suffolk and North Essex NHS Foundation Trust
Inspectors served the trust a warning notice due to concerns about people’s safety and the management of these services. Staff weren’t able to triage everyone arriving at the emergency department within their goal of 15 minutes, and some people waited …
The Ipswich Hospital
Oct 2025
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC identified significant and serious safety concerns during the surgery inspection. These related to safe staffing, escalation when people were deteriorating, record keeping and learning from incidents. Due to these issues, the trust has been told to make significant improvements …
Bishop Auckland Hospital, Darlington Memorial Hos…
Nov 2025
Fixed Penalty Notice: Shrewsbury and Telford Hospitals NHS Trust
The Care Quality Commission (CQC) issued a fixed penalty notice to Shrewsbury and Telford Hospitals NHS Trust, fining it £4,000. This was for not triaging patients within 15 minutes of attending the emergency department and not ensuring follow-ups for children …
Oct 2020
Conditions Imposed: Portsmouth Hospitals NHS Trust
The Care Quality Commission (CQC) placed four conditions on Portsmouth Hospitals NHS Trust's registration following an inspection of its urgent and emergency department. Inspectors found the emergency department at the Queen Alexandra Hospital was over-crowded with patients not being assessed …
Portsmouth
Jun 2016
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission has issued a warning notice to Mid Essex Hospital Services NHS Trust. This action was taken after concerns were raised around the flow of patients through the A&E department, whether care was being provided soon enough, …
Broomfield Hospital at Chelmsford
Aug 2015
Warning Notice: Northern Devon Healthcare NHS Trust
The Care Quality Commission (CQC) inspected medical care services at North Devon District Hospital in July following concerns about staffing levels. Inspectors found a high number of vacancies and issues with medical staff availability and responsiveness for deteriorating patients, which …
North Devon District Hospital
Nov 2021
Warning Notice: Brighton and Sussex University Hospitals NHS Trust
The Care Quality Commission told Brighton and Sussex University Hospitals NHS Trust that it must make significant improvements to its Urgent and Emergency Services, specifically concerning the Emergency Department at Royal Sussex County Hospital. Following an inspection on 22 June, …
Royal Sussex County Hospital at Brighton
Oct 2015
Conditions Imposed: The Dudley Group NHS Foundation Trust
The Care Quality Commission varied conditions on The Dudley Group NHS Foundation Trust's registration following an inspection at Russells Hall Hospital. Inspectors found concerns regarding the triage, assessment, and tracking of patients in the emergency department, especially concerning suspected sepsis. …
Russells Hall Hospital
Sep 2018
Warning Notice: North Middlesex University Hospital NHS Trust
Following an unannounced inspection in April, CQC inspectors issued a Warning Notice to North Middlesex University Hospital NHS Trust. This required the trust to significantly improve the treatment of patients attending the emergency department. Inspectors found significant delays in patient …
Jul 2016
Conditions Imposed: Portsmouth Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) placed four conditions on the registration of Portsmouth Hospitals NHS Trust following an inspection of emergency services at Queen Alexandra Hospital. CQC found that too many people were waiting too long for attention in the …
Queen Alexandra Hospital, Portsmouth
Apr 2016
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Barts Health NHS Trust following an inspection of Whipps Cross University Hospital's urgent and emergency services in July. CQC found people experienced very long waits in the emergency department, leading …
Whipps Cross University Hospital
Dec 2024
Conditions Imposed: Liverpool University Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions on Liverpool University Hospitals NHS Foundation Trust's registration under Section 31 of the Health and Social Care Act 2008. This action was taken due to significant concerns identified during an inspection, including issues …
Oct 2021
Conditions Imposed: University Hospitals of Morecambe Bay NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions upon University Hospitals of Morecambe Bay NHS Foundation Trust following an inspection of stroke services. This action was taken to ensure the trust had an effective system for managing and responding to patient …
Royal Lancaster Infirmary and Furness General Hos…
Aug 2021
Conditions Imposed: The Princess Alexandra Hospital NHS Trust
The Care Quality Commission (CQC) placed conditions on The Princess Alexandra Hospital NHS Trust's registration following an inspection in July, August and September. This action was taken due to serious concerns found regarding the lack of monitoring of patients waiting …
Nov 2021
MNSI reports(4)
Safety spotlight: Maternal deaths in the first trimester from venous thromboembolism (VTE)
Safety spotlight on maternal deaths in the first trimester from venous thromboembolism.
Themed Review
Feb 2025
Safety spotlight: Delayed escalation in abnormal CTGs
Safety spotlight on delayed escalation when cardiotocography readings are abnormal.
Themed Review
Mar 2026
Safety spotlight: Reviewing and actioning laboratory test results
Safety spotlight on the review and actioning of laboratory test results in maternity care.
Themed Review
May 2025
Safety spotlight: Incomplete observations generating incorrect early warning scores
Safety spotlight on incomplete clinical observations generating incorrect early warning scores.
Themed Review
Mar 2025