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 15 independent accountability sources, so the source mix matters as much as the headline total.
6 inquiry recs
413 PFD reports
14 committee recs
63 HSSIB recs
65 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
746 PHSO decisions
332 LGO/SPSO decisions
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(6)
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: UK Government 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 …
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: UK Government 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 …
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: UK Government 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 …
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: UK Government 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 …
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: UK Government 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 …
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: UK Government 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 …
Accepted
Prevention of Future Deaths reports(413)— showing 50 strongest matches
Keward Guy Domonic Harding
Concerns: An urgent mental health assessment was significantly delayed for over two weeks, potentially preventing detection of a decline in physical health that could have been treated.
Overdue
Luna Lesko
Concerns: Delays in essential foetal monitoring and performing a Category 2 Caesarean section, coupled with insufficient out-of-hours theatre capacity, create a real risk of preventable maternal and infant deaths.
Response (Lewisham Greenwich NHS Trust): The hospital plans to relocate elective lists to the main theatre unit by the end of January 2014, which would free up the obstetric unit theatre for emergencies and allow …
Overdue
Lucy Kilvert
Concerns: A significant delay occurred in performing a CT scan for an elderly patient on blood thinners after a fall, suggesting NICE Guidelines may not sufficiently emphasize the significance of medication in such cases.
Overdue
James Edward Mansfield
Concerns: Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Barbara White
Concerns: Critical lapses included a 12-hour absence of clinical observations, an incorrect PARS score that should have triggered intervention, and severe staff shortages. Poor handover and lack of consultant escalation further compromised care.
Overdue
Jude Augustus Gordon
Concerns: Failures in calculating and escalating Early Warning Scores, alongside a lack of national standardisation and automatic alert systems, led to delayed critical care referrals for a deteriorating patient.
Response (Department of Health): The Department of Health acknowledges the concerns, noting existing work on a national early warning score (NEWS) and the use of computerised systems in some Trusts. However, it states that …
Responded
Caroline Lee
Concerns: Medical staff failed to recognise the significance of abnormal potassium results, compounded by the laboratory's failure to inform ward staff promptly, hindering timely intervention.
Overdue
Selina Broadhurst
Concerns: Strict adherence to NICE Guidelines regarding CT head scans, which don't recommend scans without obvious neurological signs, is causing delayed or missed severe brain injury diagnoses in frail elderly patients.
Overdue
Edna Elsie Mary Eden
Concerns: Significant delays in providing prescribed antibiotics, infrequent observations with an incorrectly calculated risk score, and failures in escalating concerns about patient review delays compromised care.
Response (Heatherwood Wexham Park Hospital NHS Trust): The hospital introduced a policy (TPP 231) for managing deteriorating adult patients, requiring verification of EDOD scores. A 24-hour Central Hub system will be introduced to improve patient tracking, manage …
Responded
Stephen Palmer
Concerns: Multiple failures, including delayed assessments, lack of senior review, inappropriate unit transfer, and a complete CT scanning service failure, led to critical deterioration and suboptimal surgical management.
Overdue
Herta Woods
Concerns: Multiple failures in patient care included apparent abandonment, poor documentation, lack of senior review, incorrect fluid management leading to overload, and inappropriate cannulation, all contributing to the patient's death.
Overdue
Nathan Douthwaite
Concerns: A rectal biopsy would likely have diagnosed Hirschsprung's disease, highlighting concerns about current diagnostic guidelines and the trust's practices in this regard.
Response (Department of Health): The Department of Health acknowledges the coroner's concerns but states that NICE has the statutory function of producing clinical guidelines. NHS England will disseminate the case to NHS learning networks …
Overdue
Margaret Easterfield
Concerns: A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Overdue
Noel Williams
Concerns: The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for surgery, to the anaesthetist and surgeon, potentially affecting treatment plans.
Overdue
Jean James
Concerns: Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Response (City Hospitals Sunderland): The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the …
Responded
Matthew Simmonds
Concerns: An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.
Overdue
Kerry Jacobs
Concerns: The hospital lacked a policy requiring doctors to document reasons for prescribing medication outside BNF guidelines. There was also no protocol for pharmacists and clinicians to discuss queried medication dosages.
Response (Surrey Sussex Healthcare NHS Trust): The Chief Medical Officer issued a directive for staff to record the rationale for prescribing medication outside of BNF guidance, and the Chief Pharmacist has reiterated the medication screening procedure …
Responded
John Dodd
Concerns: Inadequate patient monitoring, including missed INR checks and unreported temperature rise, coupled with significant delays in A&E medical assessment, compromised patient safety.
Response (The Dudley Group NHS Foundation Trust): The Trust will develop a written guideline to include routine checking of INR for all patients presenting after a fall who are receiving vitamin-K antagonist anticoagulants. The Emergency Department will …
Responded
Gary Bradshaw
Concerns: The hospital experienced significant delays in diagnosis, inappropriate medication prescribing before test results, inadequate patient monitoring, and poor communication/IT systems, leading to suboptimal care.
Response: Stockport NHS Foundation Trust has purchased the Patientrack electronic tracking system which is being piloted and evaluated, with phased rollout planned across the Trust, starting with vital sign input in …
Response (Department of Health): The Department of Health acknowledges the concerns and highlights existing national guidance (NICE, Royal College of Physicians) on early warning scores and the care of acutely ill patients, noting that …
Responded
Gregg O’Reilly
Concerns: The coroner noted a missed opportunity to refer the deceased to critical care, and the lack of observation records during a critical period before the deceased suffered a second bleed and cardiac arrest.
Response (Barts Health NHS Trust): Barts Health NHS Trust has concluded an investigation and outlined recommendations including recruiting a Band 7 Sister, shortening the transition to an electronic patient record, establishing a Critical Care Board …
Responded
Frances Bell
Concerns: The investigation lacked a Root Cause Analysis and senior clinical input, coupled with unacceptable delays in patient transfer to theatre for critical treatment.
Overdue
Samuel Openshaw
Concerns: Slow electronic transfer of echocardiograph studies to specialist centers and high workload of paediatric retrieval teams pose significant risks for urgent child transportation and care.
Overdue
Peter Hinchliffe
Concerns: Significant delays in diagnostic investigations across both private and NHS sectors, coupled with inconsistent advice and management for young athletes experiencing syncope, pose a continuing risk.
Overdue
Ashley Ponsonby
Concerns: Poor communication by a locum SHO regarding observation plans and failure to suggest Naloxone for drug overdose led to inappropriate management and monitoring of a deteriorating patient.
Response (Greater Manchester Police): • Greater Manchester Police agrees that a mental disorder does not absolve individuals of the criminal consequences of their actions. • It is often appropriate and necessary for legal proceedings …
Responded
Albert Flynn
Concerns: Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.
Response (Lester Aldridge LLP): HC-One Limited will re-emphasise the need to call for qualified assistance during individual supervision for staff and induction for new staff, and senior care staff involved in this incident will …
Responded
Peter White
Concerns: Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Overdue
Joyce Nelson
Concerns: Significant delays in doctor assessment and imaging results in the Emergency Department, caused by national shortages of emergency medicine doctors and radiologists, led to misdiagnosis and potential unsafe discharge.
Overdue
Evelyn Smith
Concerns: Inaccurate vital sign recording and lack of clinician knowledge regarding pediatric early warning and croup severity scoring systems hindered early recognition of illness and effective data entry in GP records.
Overdue
Linda Rignall
Concerns: A patient's significant clinical deterioration, recorded on a NEWS chart, was not reported to a doctor or assessed promptly, risking future deaths.
Overdue
Mr Pether
Concerns: Inadequate monitoring and assessment of a patient's wound, delayed identification of infection, and insufficient re-consideration of treatment options despite deteriorating clinical condition.
Overdue
Ella Block
Concerns: Opportunities for timely sepsis treatment in children may be missed because newly qualified clinicians struggle to identify this rare but fatal condition.
Overdue
Stephen Atherton
Concerns: The deceased required multiple, increasingly complex investigations, suggesting potential issues in initial diagnostic pathways or management of his condition.
Overdue
Yaser Saleh
Concerns: The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.
Overdue
Kirsty Pritchard
Concerns: There were communication failures between community and inpatient teams regarding the patient's post-discharge contacts, delaying self-harm risk assessment. Deficiencies also existed in systems for locating the patient during crises.
Response (Black County NHS Trust): A protocol has been developed to ensure that if telephone contact cannot be established with a service user assessed to be in immediate risk of harm or death within 30 …
Responded
Sonielia Holmes
Concerns: The report identifies that doctors had difficulty contacting the Haematology Department at the Hospital and haematologists failed to respond to messages requesting advice and review of the patient.
Overdue
Agnes Hannan
Concerns: Critical issues included unavailable hospital records, poor staff communication and handover, inadequate nursing observations, and a lack of consultant oversight. Delays in CT scanning and end-of-life discussions were also noted.
Response (Tameside Hospital NHS Trust): The hospital replaced its computer system for medical records, is purchasing a scanner for the A&E department to improve record accessibility, and has reviewed and updated its DNACPR policy, emphasizing …
Responded
Sandra Higham
Concerns: A highly fatal complication of atrial ablation, atrial-oesophageal fistula, is difficult to diagnose due to non-specific symptoms and low medical awareness within the wider profession.
Response (BHRS): BHRS will include an article on avoidance and recognition of atrio-oespohageal fistula in its winter newsletter and remind members to ensure this complication is recorded in the national cardiac rhythm …
Response (UK Health Security Agency): Public Health England states that the case is not something they can directly assist with, but understand that the Department of Health will contact appropriate bodies.
Response (Department of Health): The Department of Health contacted the BCS who are considering circulating a letter to relevant surgeons. A copy of the coroner's letter and the response from the Department of Health …
Responded
Mary Hallworth
Concerns: A patient experiencing pain after a fall did not receive medical attention or assessment for a critical 24-hour period.
Overdue
Mark Hudson
Concerns: Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): The Trust has undertaken training with senior members of the CICU Team, who are now competent in the placement of iGel tubes. A policy of using end tidal carbon monoxide …
Responded
Peter Dorney
Concerns: Nurses lacked mandatory training on Early Warning Scores (EWS), resulting in non-adherence to protocols critical for patient well-being and timely intervention.
Response (North Bristol NHS Trust): North Bristol NHS Trust clarified that all new nurses receive mandatory Early Warning Score (EWS) training on induction and that 93% of all nurses have received EWS training. The directorate …
Responded
Harold Penny
Concerns: The radiology department lacked a system to urgently report critical findings, such as a displaced urinary catheter causing a blockage, or to rectify such issues themselves.
Response (Tameside Hospital NHS Trust): The Trust is developing a 'Radiology Requesting and Reporting Policy' and has established a Results Governance Steering Group to improve patient safety related to radiology. The response details responsibilities for …
Responded
Stephen Mayoll
Concerns: The hospital failed to re-assess out-patients for DVT risk according to policy and experienced delays in making fracture clinic notes available, risking patient safety.
Response (Portsmouth Hospitals NHS Trust): Patients returning to the fracture clinic with lower limb injuries will have a reassessment of their VTE risk factors. A scanner has been ordered to digitally save and record reviews …
Responded
Freda Owens
Concerns: There was a significant breakdown in information gathering and exchange between medical professionals, leading to incorrect assumptions about patient injuries, delayed specialist involvement, and suboptimal care.
Overdue
Mikey Hornby
Concerns: The out-of-hours service repeatedly failed to appreciate the seriousness of an infant's condition, delaying hospital admission and critical antibiotic treatment. The GP surgery also lacked essential diagnostic facilities.
Response (Bridgewater Community Healthcare NHS Trust): Bridgewater Community Healthcare NHS Foundation Trust has taken several actions, including updating the Out of Hours Triage Policy, developing a Paediatric Early Warning System (PEWS) and escalation aid, and delivering …
Responded
David Mountain
Concerns: Post-pacemaker insertion, chest pain and bleeding risks were not fully investigated for days, with a critical echocardiogram delayed and its results unavailable before the patient's death.
Response (The Queen Elizabeth Hospital): The Queen Elizabeth Hospital has implemented clear guidance for doctors on investigating patients admitted after pacemaker insertion and implemented a system for cardiac technicians to directly contact clinical teams about …
Responded
Philip Smith
Concerns: Extensive failures in nursing and doctors' record-keeping, including missed observations and medications. A junior doctor also declined a senior medical review despite a nurse's concerns about the patient's deterioration.
Overdue
Susanna Geraty
Concerns: Post-operative care failures included inadequate fluid balance monitoring and recording, poor nursing records, failure to recognise an acutely unwell patient, and unaddressed family concerns.
Response (Surrey Sussex NHS Trust): SASH has introduced mandatory training for newly qualified nurses on fluid balance and has issued a reminder to staff regarding the importance of accurately completing fluid balance charts. A Serious …
Responded
Lana-Liza Chervonenko
Concerns: High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Overdue
Brian Marks
Concerns: PEJ and PEG tubes are easily confused due to their similar appearance, highlighting the lack of a simple colour-coding system for differentiation.
Response (Department of Health): The MHRA will bring the issue of tube misidentification to the attention of the Standards Committees and intends to include the risk of misidentification of similar devices in the next …
Responded
Select committee recommendations(14)
#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 …
Gov response: 1.7 The Elective Reform Plan (ERP) set out several commitments aimed at tackling health disparities in access to and waiting time for elective care, including the publication of waiting list information disaggregated by demographic information, …
Accepted
#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 Pending
#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. …
Gov response: • NHS England and NHS Improvement continue working in partnership with HMPPS colleagues to ensure that all vulnerable patient populations are managed and supported through healthcare and supported through an appropriate enablement process to engage …
Position Not Stated
#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 …
Gov response: This government recognises that women suffering with gynaecological conditions have been failed for far too long, and we acknowledge the impact that long wait times for diagnosis and treatment for conditions such as endometriosis have …
Position Not Stated
#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 …
Gov response: We recognise the opportunities for making every contact count across the health system, in line with best practice. The suggested contact points are delivered in a range of settings by a range of healthcare professionals. …
Position Not Stated
#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 …
Gov response: 5.1 The government agrees with the Committee’s recommendation Recommendation implemented 5.2 The number of cases where a medical condition must be investigated before a licence can be issued have returned to normal levels. The DVLA …
Not Addressed
#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 …
Gov response: The government disagrees with the Committee’s recommendation. The department is currently unable to agree to this recommendation as Ministers will need to decide whether and how any strategic review or alternative action is undertaken. Ministers …
Not Accepted
#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 …
Gov response: Income replacement benefits such as Employment and Support Allowance have a rate of payment during the assessment phase because the Department can establish a need at the outset—being out of work. PIP is not an …
Position Not Stated
#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. …
Gov response: The new Functional Assessment Service contracts include specific end-to-end clearance targets for: PIP Services WCA Services Special Rules for End of Life The Department will assess providers’ delivery against these targets under the performance regime. …
Position Not Stated
#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 …
Gov response: The Committee has a crucial role in holding PHSO’s independent service to account. As an Officer of the House, the Ombudsman is fully committed to being open and transparent about the performance of the service …
Under Consideration
#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.
Gov response: The experience of the demands placed on the NHS during the COVID-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS. …
Accepted
#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 …
No Published Response
#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 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date Spring 2023 4.2 Delivery of the Elective Recovery Plan, and the initiatives deployed to achieve it, will be closely monitored by both the department …
Accepted
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The government’s vision is to create a world class treatment and recovery system in line with the recommendations of Dame Carol Black’s independent review …
Accepted
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
CQC inspection actions(65)— showing 50 strongest matches
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
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
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
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
Ormskirk District General Hospital
The service must ensure staff accurately complete, and document modified early obstetric warning scores and newborn risk assessments, record CTG assessments and fresh eyes in order to identify and escalate women, birthing people and babies at risk of deterioration.
Must Do
North Devon District Hospital
The service must ensure systems are used to effectively monitor and manage women and birthing people requiring an induction of labour, in particular, that checks are carried out within a safe time frame in line with national guidance.Regulation12(2)(a)(b)
Must Do
North Devon District Hospital
The service must ensure staff comply with systems for the accurate interpretation and escalation of electronic fetal monitoring and is regularly audited.Regulation12(2)(a)(b)
Must Do
Liverpool Women's Hospital
The trust must ensure that staff complete and record full sets of observations in the intrapartum period and effectively monitor for deterioration.
Must Do
Leighton Hospital
The service should ensure it continues to monitor staff compliance with completing and escalating baby early warning scores so that all babies are risk categorised at birth.
Should Do
Leicester Royal Infirmary
The trust must ensure that the use of MEOWS is consistently implemented across the service in line with the policy.
Must Do
Leicester Royal Infirmary
Care and treatment must be provided for patients in a safe way. The trust must ensure staff are assessing the risks to the health and safety of patients of receiving the care or treatment. Staff must be doing all that …
Must Do
Leicester General Hospital
The trust must ensure that the use of MEOWS is consistently implemented across the service in line with the policy.
Must Do
Kettering General Hospital
The service should ensure that observation rounds are undertaken in a timely manner to minimise delay in identifying deteriorating patients.
Should Do
Kettering General Hospital
The servicemust ensure effective systems are in place and fully implemented to assess and treat patients at risk of sepsis in a timely manner. This includes but is not limited to ensuring antibiotics are administered within 1 hour of suspecting …
Must Do
Kettering General Hospital
The servicemust ensure patients showing signs of deterioration or those at risk of sepsis are reviewed by an appropriate grade clinician and treated in a timely manner in line with Sepsis 6 pathways and trust deteriorating patient policies.
Must Do
Kettering General Hospital
The servicemust ensure patient observations are completed in a timely manner in line with National Early Warning Score frequency rules to ensure deteriorating patients can be quickly identified and escalated.
Must Do
Kettering General Hospital
The servicemust continue the work to ensure patients can access treatment in a timely way and in line with national standards. This includes but is not limited to undergo timely assessments, time to triage, first set of observations, medical assessments …
Must Do
Kettering General Hospital
The servicemust ensure national guidance is followed and patients arriving by ambulance receive a face-to-face triage and assessment of their clinical needs.
Must Do
Kettering General Hospital
The servicemust ensure effective systems are in place and fully implemented to treat paediatric and adult patients at risk of sepsis in a timely manner and in line with national guidance.
Must Do
Kettering General Hospital
The servicemust ensure patient risks are fully assessed and mitigated in a timely manner. This includes but is not limited to; tissue viability, falls and deterioration.
Must Do
Great Western Hospital
The service should ensure that staff are compliant with MEOWS and ensure effective audit programme is in place.
Should Do
Ellesmere Port Hospital
The trust should ensure staff improve the compliance of completing the sepsis screening tool on the electronic patient record.
Should Do
Doncaster Royal Infirmary
The trust must ensure that all staff know the emergency procedures that are in place for patients who may deteriorate.
Must Do
Yeovil District Hospital
The service must ensure staff accurately complete, and document modified early obstetric warning scores and newborn assessment observation and early warning score forms in order to identify and escalate women and birthing people and babies at risk of deterioration.
Must Do
The James Cook University Hospital
The service must monitor compliance with the calculation, escalation and timely review of MEOWS and take action to improve compliance, and ensure instances of deterioration are identified and actioned promptly
Must Do
St Helier Hospital and Queen Mary's Hospital for Children
The service must ensure staff accurately complete, and document modified early obstetric warning scores in order to identify and escalate women and birthing people at risk of deterioration.
Must Do
Royal Berkshire Hospital
The service should ensure staff escalate women and birthing people and babies at risk of deterioration appropriately.
Should Do
Queen Alexandra Hospital
The service should ensure staff complete timely reviews for each woman in triage in line with the trust policy.
Should Do
Epsom General Hospital
The service must ensure staff accurately complete, and document modified early obstetric warning scores in order to identify and escalate women and birthing people at risk of deterioration.
Must Do
BMI Southend Private Hospital
The service must ensure that there are safe processes in place for monitoring of the deteriorating patient. Including the safe transfer of a patient to another healthcare facility.
Must Do
University Hospital Lewisham
The service should ensure staff complete and document fresh eyes observations in line with national guidance.
Should Do
The Princess Royal Hospital
The trust should ensure that all staff in neonates have completed sepsis training.
Should Do
The Princess Royal Hospital
The service should consider how it introduces a system to ensure the correct use of fluid balance charts.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatdailychecksofemergencyboxesforhypoglycaemia,cordprolapse,sepsisandpre-eclampsiatakeplaceaspolicy.Regulation12(1)(2)(g)
Must Do
Kettering General Hospital
The service should ensure staff follow guidance and provide worsening advice to patients leaving the emergency department before being seen.
Should Do
St Helier Hospital and Queen Mary's Hospital for Children
The service should ensure ‘fresheyes’ checks of cardiotocography (fetal heart rate) monitoring are carried out hourly.
Should Do
Queen Alexandra Hospital
The service should ensure staff complete and document fresh eyes and fresh ears observations in line with national guidance.
Should Do
Epsom General Hospital
The service should ensure ‘fresheyes’ check of cardiotocography (fetal heart rate) monitoring are carried out hourly.
Should Do
Kingsley Nursing Home
The registered manager and provider failed to: 2. monitor people's healthcare conditions and refer them to health professionals in a timely way. 12 (2a and b)
Must Do
Worcestershire Royal Hospital
The trust should have systems or processes to assess, monitor and identify improvements of the quality and safety of sepsis management.
Should Do
William Harvey Hospital
The trust should ensure patient call bells are answered promptly.
Should Do
The Queen Elizabeth Hospital
The service must ensure women and birthing people are seen within appropriate timelines by medical staff when presenting to maternity triage.
Must Do
Royal Sussex County Hospital
The trust must ensure the nutritional and hydration needs of patients are met. This includes establishing an effective system for patients to be supported by staff at mealtimes in order to maintain adequate nutrition and hydration. This also includes ensuring …
Must 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)
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 …
Sep 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
Article 2 learning points(1)
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