Disease outbreak surveillance
Insufficiently comprehensive or risk-based surveillance activities by APHA, leading to reduced capacity to detect new disease threats.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
17 inquiry recs
26 PFD reports
355 committee recs
2 HSSIB recs
15 CQC actions
1 PPO rec
15 NAO recs
24 IMB recs
5 IMB reports
1 patient safety alert
1 Scottish FAI
1 DHR rec
5 PHSO decisions
38 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(17)
COVID-M3.8 — Recording Healthcare Worker Deaths
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in …
Gov response: The government agrees that, in the event of a future pandemic, data on healthcare worker deaths plays a vital role in supporting and protecting the workforce as well as improving epidemic surveillance. The government will …
Accepted
COVID-M3.1 — IPC Structures and Transmission Risk
Recommendation: The UK government must ensure that there is a body (equivalent to the UK Infection Prevention and Control Cell) in place ready to be convened at the outset of any future pandemic, to consider and draft infection prevention and control …
Gov response: The government recognises the importance of clear, accountable structures to support IPC decision making during a pandemic and agrees with the Inquiry’s recommendation.
Accepted
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in …
Gov response: The government agrees with the Inquiry that data systems need to be improved to identify individuals at high risk during a pandemic. The government’s 10 Year Health Plan and existing data policy work provide a …
Accepted
R71 — National CDI death monitoring
Recommendation: Scottish Government should identify a national agency to undertake routine national monitoring of deaths related to CDI.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R53 — Surveillance systems fit for purpose
Recommendation: Health Boards should ensure that surveillance systems are fit for purpose, are simple to use and monitor, and provide information on potential outbreaks in real time.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R16 — CDI outbreak reporting
Recommendation: Health Boards should ensure that the nurse in charge of each ward reports suspected outbreaks of CDI (as defined in local guidance) to the Infection Control Team.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R4 — Local HAI Task Forces
Recommendation: Scottish Government should develop local Healthcare Associated Infection (HAI) Task Forces within each Health Board area.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
F107 — Sharing concerns
Recommendation: If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients …
Gov response: Accepted. Public Health England is reviewing its governance framework which underpins its responsibilities (in partnership with local, regional and national partners) for sharing and escalating concerns. As part of this work and as new structures …
Accepted
F106 — Health Protection Agency Coordination and publication of providers' information on healthcare associated infections
Recommendation: The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health and Social Care Information Centre.
Gov response: Accepted. Public Health England, which since April 2013 has taken on the functions of the Health Protection Agency, is working together with the Health and Social Care Information Centre to coordinate the collection, analysis and …
Accepted
R54 — Surveillance system training
Recommendation: Health Boards should ensure that the users of surveillance systems are properly trained in their use and fully aware of how to use and respond to the data available.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R40 — Prudent antibiotic prescribing
Recommendation: Health Boards should ensure that the key principles of prudent antibiotic prescribing are adhered to and that implementation of policy is rigorously monitored by management.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R35 — Antibiotic prescribing monitoring
Recommendation: Scottish Government should monitor the implementation of policies and/or guidance on antibiotic prescribing issued in connection with healthcare associated infection and seek assurance within specified time limits that implementation has taken place.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R34 — Antimicrobial guidance implementation
Recommendation: Health Boards should ensure that changes in policy and/or guidance on antimicrobial practice issued by or on behalf of Scottish Government are implemented without delay.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R3 — IPC policy review
Recommendation: Health Boards should ensure that infection prevention and control policies are reviewed promptly in response to any new policies or guidance issued by or on behalf of the Scottish Government, and in any event at specific review dates no more …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R2 — HAI implementation strategy
Recommendation: Scottish Government should ensure that policies and guidance on healthcare associated infection are accompanied by an implementation strategy and that implementation is monitored.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
F108 — Support for other agencies
Recommendation: Public Health England should review the support and training that health protection staff can offer to local authorities and other agencies in relation to local oversight of healthcare providers' infection control arrangements.
Gov response: Accepted. Public Health England recognises the importance of supporting local infection control and prevention arrangements, and has undertaken a review. Although the offer of support and training would be a significant undertaking, Public Health England …
Accepted
R55 — CDI reporting to CEO and Board
Recommendation: Health Boards should ensure that numbers and rates of CDI are reported through each level of the organisation up to the level of the Chief Executive and the Board. Reporting should include positive reporting in addition to any exception reporting. …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
Prevention of Future Deaths reports(26)
Carla London
Concerns: The coroner noted a need to consider NICE guidance on late-onset sepsis in babies under 1500g and for further research into infection monitoring systems like HeRO.
Response (Department of Health): • The Department stated that plans include an audit of GP surgery practice by March 2015 and a new tool for GPs to diagnose sepsis in children under 5. • … (AI summary)
Responded
Terence Brooks
Concerns: The coroner noted the hospital lacked understanding in interpreting Legionella water sample results, leading to an erroneous conclusion about the infection source. There was no established procedure for investigating Legionella outbreaks.
Overdue
Ana Sirghi-Marin
Concerns: The coroner identified that discoloured amniotic fluid, even when not purulent or blood-stained, should always be sent for immediate microbiological analysis with prompt follow-up of results. A guideline implementing this action is recommended as a wise precaution.
Response (Royal College of Obstetricians Gynaecologists): • The Royal College of Obstetricians and Gynaecologists' Guidelines Committee stated that the coroner's recommendations will be taken into consideration during the next revision of the Green-top guideline. (AI summary)
Overdue
Dylan Hill
Concerns: There are no formal procedures for health services to report non-fatal anaphylactic reactions caused by commercial food premises to regulatory bodies like Trading Standards. This lack of communication prevents timely intervention and appropriate action regarding allergen risks at such premises.
Response (Food Standards Agency): • The Food Standards Agency (FSA) provided stakeholders with messaging on allergen information and labelling rules and clarified enforcement in the Food Law Code of Practice and Practice Guidance. • … (AI summary)
Response (Barnsley Hospital NHS Trust): • The anaphylaxis draft protocol was reviewed and updated. • The revised protocol includes a referral form to inform Trading Standards of anaphylactic reactions linked to commercial food premises. • … (AI summary)
Response (Department of Health): • The Food Standards Agency (FSA) intends to establish cross-government discussions to consider the matter of reporting non-fatal anaphylaxis. • Barnsley and Sheffield are exploring the development of local notification … (AI summary)
Responded
Lauren Sandell
Concerns: The coroner notes confusion regarding responsibility for vaccinating children who miss school programmes before university, especially as the MenW vaccination is an optional GP service. There is no clear audit to ensure GP practices identify and vaccinate these children.
Response (NHS England): • NHS England clarified that service specifications delineate responsibilities for vaccination delivery through school-based and GP practice services. • NHS England confirmed that GPs must inform commissioners if they do … (AI summary)
Overdue
Natasha Ednan-Laperouse
Concerns: The coroner identified inadequate allergen labelling and a lack of coordinated monitoring for allergic reactions at Pret-a-Manger, alongside concerns about Epipen auto-injectors having insufficient needle length and a lower adrenaline dose than recommended.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare Products Regulatory Agency (MHRA) required manufacturers to disclose exposed needle length for adrenaline auto-injectors in product information. • The MHRA implemented additional warnings and disclosed … (AI summary)
Response (Department for Environment Food Rural Affairs): • An urgent review of allergen information provision for food pre-packed for direct sale is underway to strengthen the framework. • The Department aims to launch a consultation on allergen … (AI summary)
Overdue
Sebastian Clark
Concerns: The coroner noted the absence of a national programme for streptococcal infection screening in labouring women and suggested consideration of a national policy similar to Kingston Hospital's guidance on pyrexia and suspected chorioamnionitis.
Overdue
Tien Phung
Concerns: The coroner notes that Strongyloides stercoralis forms are not routinely screened for prior to transplant surgery, despite the infection being treatable if identified early and prevalent worldwide.
Response (NHS Blood and Transplant): • NHS Blood and Transplant (NHSBT) reviewed the donor's clinical information and requested further testing, which confirmed the recipient had Strongyloides infection prior to transplant. • NHSBT and the British … (AI summary)
Overdue
Zona Tebbs
Concerns: The coroner identifies a failure to effectively communicate key changes in clinical practice and updated medical guidance to healthcare professionals, noting that requiring practitioners to navigate multiple links increases the risk of information being overlooked.
Overdue
Brenda Elmer
Concerns: The coroner raised concerns about the lack of communication to out-of-area hospital patients regarding a Listeria outbreak, which delayed diagnosis. They also noted no legal requirement for private labs or hospitals to share Listeria isolates, impeding early outbreak identification.
Response (UK Health Security Agency): • PHE hosted a multi-agency lessons learned exercise following the outbreak. • PHE wrote to national microbiological standards, resulting in an updated Standard Operating Procedure advising hospital laboratories to refer … (AI summary)
Responded
Leslie Harris
Concerns: The coroner raised concerns regarding the interpretation of Public Health England guidance on patient movement to Covid-19 isolation wards, noting that varied interpretations across trusts could put vulnerable patients at risk of infection.
Response (NHS England): • The national IPC guidance was updated on 20 August 2020 to include examples for managing COVID-19 risks through specific pathways. • A further update to the guidance was published … (AI summary)
Response (UK Health Security Agency): • Public Health England (PHE) updated its guidance on managing staff and exposed patients, including on 4th April 2020 and 15th May 2020, to strengthen advice on isolation and cohorting. … (AI summary)
Responded
Brian Mottram
Concerns: The coroner noted GP surgeries in Tameside predominantly used telephone appointments, potentially delaying COVID-19 identification and treatment. Concerns were also raised regarding the clarity of processes for identifying high-risk COVID-19 cases or when to conduct additional assessments for vulnerable patients.
Response (Tameside and Glossop CCG): • The CCG described its Tameside and Glossop CCG/LMC GP Guidance v19, which provided routes to manage patients requiring consultations based on COVID symptoms, including remote triage and risk stratification. … (AI summary)
Responded
Karen Starling and Anne Martinez
Concerns: The coroner highlights an incomplete understanding of M abscessus in hospital water systems. Health Technical Memorandum 04-01 lacks specific guidance for identifying, controlling, or testing for M abscessus, especially for immunosuppressed patients and new hospitals.
Response (NHS England): • NHS England provided oversight and support to Royal Papworth Hospital, including establishing incident management meetings and facilitating collaboration with UKHSA. • NHS England's National Principal Engineer conducted a site … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care acknowledged receipt of the letter regarding the deaths of Karen Starling and Anne Martinez. • The Department stated that Health Technical Memorandums … (AI summary)
Responded
Alexandra Briess
Concerns: The coroner identified a need for a robust national system to capture and record fatal and near-fatal anaphylaxis cases, and to fund appropriate research to improve understanding and prevent future deaths.
Response (NHS England): • The Immunology and Allergy Clinical Reference Group is reviewing the specialised allergy service specification. • NHS England's National Patient Safety Team is developing a mechanism for sharing patient safety … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care and the National Allergy Strategy Group have jointly established an Expert Advisory Group for Allergy (EAGA) to identify priority areas and advise … (AI summary)
Overdue
Kimberley Sampson and Samantha Mulcahy
Concerns: The coroner noted a lack of specific national guidance on prescribing antiviral medication for Herpes Simplex in post-partum women with systemic infection, and insufficient awareness of it as a potential diagnosis in sepsis pathways.
Response (NHS England): • NHS England engaged with the UK Health Security Agency and East Kent Hospitals University NHS Foundation Trust following receipt of the report. • NHS England discusses all PFD reports … (AI summary)
Response (Royal College of Obstetricians and Gynaecologists): • The Royal College of Obstetricians and Gynaecologists is updating its Green-top Guidelines on Sepsis in pregnancy and following pregnancy. • The updated guideline will contain guidance on the timely … (AI summary)
Responded
Carrianne Franks
Concerns: The coroner noted concerns that clinical guidelines do not identify healthcare professionals as a heightened risk group for TB exposure, and the definition of 'close contact' for staff notification is too narrow. There is also insufficient education for NHS staff on TB symptoms, and the 'warn and inform' process needs to broaden for highly transmissible cases to include all staff.
Response (NHS England): • NHS England and UKHSA are working with NICE to update TB contact tracing guidance, with a focus on healthcare workers. • UKHSA is undertaking an updated analysis of TB … (AI summary)
Response (UK Health Security Agency): • UKHSA is undertaking analysis of data on active TB disease in healthcare workers and initiated a review of TB transmission in healthcare settings, with publication and completion expected within … (AI summary)
Response (National Institute for Health and Care Excellence): • The report has been shared with the guideline surveillance team to assess new evidence relating to TB contact tracing. • NICE plans to meet with the UK Health Security … (AI summary)
Responded
Sienna Barber
Concerns: The coroner noted the absence of specific NICE guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups. The report also highlighted that a NICE review of rapid antigen testing excluded children under five, where such testing could be beneficial.
Response (Nation Institute for Health and Care Excellence): • NICE stated it had produced several guidelines relevant to children presenting with fever, including NG143, NG51, and NG84. • NICE stated it had published diagnostic guidance on rapid tests … (AI summary)
Response (Manchester University Foundation Trust): • The Trust liaised with the Greater Manchester Sudden Unexpected Death of a Child team, Public Health England, and the Greater Manchester Child Death Overview Panel to raise concerns. (AI summary)
Response (Department of Health and Social Care): • NHS England published interim clinical guidance on the diagnosis and treatment of children with Group A Streptococcus. • A campaign was commenced to inform parents and carers about Group … (AI summary)
Response (Royal College of Paediatrics and Child Health): • The Royal College of Paediatrics and Child Health endorsed the reinstatement of the NICE Sore Throat (Acute) NG84 guideline. • The College will share information and suggestions from the … (AI summary)
Responded
Laura Farmer
Concerns: The UKHSA's information gathering regarding the E coli source was incomplete, and crucial details from the family were not sought. Public health authorities also did not provide adequate safety advice to the family or feedback to treating clinicians, making it difficult for the family to obtain information.
Response (UK Health Security Agency): • UKHSA conducted an enhanced surveillance questionnaire with Mrs. Farmer and provided infection prevention and control advice. • A senior clinician contacted the next of kin to discuss their concerns … (AI summary)
Response (UCLH): • UCLH gathered input from its microbiology, Infection Prevention and Control (IPC), haematology, and Intensive Care Unit nursing leadership teams. • UCLH stated that its IPC nurses review infectious patients, … (AI summary)
Responded
Patricia Lines
Concerns: The coroner raised concerns about the national guidance for skin cleaning prior to injections, which suggests cleaning is not necessary if skin is clean. The report noted this advice, based on dated evidence, contrasts with the bacterial reduction achieved by alcohol wipes.
Response (NHS England): • NHS England stated it would review the contents of UKHSA’s response regarding 'The Green Book' once received. (AI summary)
Response (UK HSA): • UKHSA stated that its 'Green Book' guidance advises that only visibly dirty skin needs to be washed with soap and water before vaccinations, and disinfection is not necessary. • … (AI summary)
Response (Browney House Surgery): • The practice discussed the report with clinicians and management staff. • The case will be used as a learning exercise in clinical staff appraisals. • Clinical staff will enroll … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care reviewed the concerns outlined in the report. • The Department of Health and Social Care determined that UK Health Security Agency (UKHSA) … (AI summary)
Responded
Wessam al Jundi
Concerns: The coroner noted current surveillance programs for respirable crystalline silica (RCS) exposure are insufficient due to rapid disease onset. Many companies working with artificial stone products lack safe working conditions, adequate dust suppression, PPE, and ventilation.
Response (Health and Safety Executive): • The Health and Safety Executive (HSE) updated its supplementary guidance for occupational health professionals on health surveillance for respirable crystalline silica (RCS) exposure in May 2024. • HSE met … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it had no comments or suggestions regarding the document. • The Department indicated that responsibility for the coroner's concerns sits with … (AI summary)
Response (Agglomerated Stone Manufacturers Association): • The Agglomerated Stone Manufacturers Association (A.St.A) stated that it and its members have advocated for awareness, provided warning stickers and data sheets, and created educational materials to protect workers. … (AI summary)
Response (Worktop Fabricators Federation): • The industry has explored creating controls at the point of entry for engineered stone, potentially requiring release only to licensed distributors or registered fabrication businesses, with provenance certification. • … (AI summary)
Response (MHCLG): • MHCLG requested an extension to the 56-day period for a formal response. • MHCLG stated that the concerns raised fell within the remit of the Health and Safety Executive … (AI summary)
Responded
Edward Jones
Concerns: The trust's Sepsis Screening Tool (SST) was not deployed in the patient's assessment. Work was ongoing to ensure consistent application of the SST between the Paediatric Emergency Department and paediatric in-patient units.
Response (National Institute for Health and Care Excellence): • Senior clinical advisers within the patient safety team reviewed the concerns raised in the report. • NICE plans to update its guidance on paediatric sepsis in 2026. • NICE … (AI summary)
Responded
Mia Lucas
Concerns: The coroner noted a lack of national guidance for clinicians on when to consider and how to diagnose Autoimmune Encephalitis, which could lead to the condition not being identified and increase the risk of future deaths.
Response (Royal College of Psychiatrists): • The Royal College of Psychiatrists has developed national clinical guidance on autoimmune encephalitis and autoimmune psychosis, which is in its final drafting stages. • This guidance was developed through … (AI summary)
Response (British Paediatric Neurology Association): • The British Paediatric Neurology Association stated it would be keen to be involved in the commissioning of a NICE Guideline on Autoimmune Encephalitis. (AI summary)
Response (NHS England): • National Guidelines for the management of Encephalitis, which include a section on Autoimmune Encephalitis, are available. • These guidelines are being updated to include a larger section on Autoimmune … (AI summary)
Responded
Chloe Ulett
Concerns: The coroner highlighted a lack of routine ammonia testing and clear national guidelines for adults presenting with acute behavioural change and confusion. The Royal College of Emergency Medicine's guidance was not embedded in practice and lacked specificity for diagnosing rare metabolic disorders, including post-partum presentations.
Response (Royal College of Midwives): • The Royal College of Midwives stated it would reinforce education for midwives on recognising acute changes in mental status and their clinical significance. • The Royal College of Midwives … (AI summary)
Response (Faculty of Intensive Care Medicine): • The Faculty stated it would highlight this case in its tri-annual Safety Bulletin. • The Safety Bulletin would signpost open access resources and highlight the utility of ammonia testing … (AI summary)
Response (National Institute for Health and Care Excellence): • NICE stated it does not have specific guidance on N-acetylglutamate synthase deficiency or hyperammonaemia detection. • NICE indicated that this area is best addressed by specialist societies. • NICE … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians (RCP) committed to raising the profile of hyperammonaemia by sharing this issue with its members via the RCP website. • The RCP stated it … (AI summary)
Response (Royal College of Obstetricians and Gynaecologists): • The Royal College of Obstetricians and Gynaecologists commissioned an article on 'Metabolic Conditions in the Peripartum Period' for publication in The Obstetrician and Gynaecologist Journal. (AI summary)
Response (The Royal College of Emergency Medicine): • The Royal College of Emergency Medicine stated it would amend its guidance to include an addition regarding metabolic conditions rarely causing Acute Behavioural Disturbance. • The Royal College of … (AI summary)
Responded
Eden Henry
Response (Association of Directors of Public Health): The Association of Directors of Public Health London plans to hold a session with partners to share learning from the PFD, promote clinical guidance, and encourage review of transition arrangements … (AI summary)
Response (Department of Health and Social Care): The Department of Health and Social Care is developing new guidance for commissioning and delivery of care for people transitioning from residential treatment to supported housing, and working on guidance … (AI summary)
Responded
Tung Tran
Response (British Association for the study of the Liver): BASL clarified that its role does not include developing national clinical guidelines. However, it plans to incorporate hepatitis B reactivation risks and prevention into its upcoming webinar and conference programmes, … (AI summary)
Response (UK Health Security Agency): The UKHSA stated it is not responsible for commissioning NHS treatment and care programmes and therefore cannot address the concerns, advising the PFD report be redirected to NHS England specialised … (AI summary)
Response (NHS England): NHS England will develop and publish a national circular, engage Operational Delivery Networks, and integrate the hepatitis B reactivation prevention pathway into the Viral Hepatitis Patient Management System. It has … (AI summary)
Responded
Tung Tran
Concerns: The coroner noted a lack of national guidance on monitoring and prescribing for hepatitis B reactivation prevention. Concerns were also raised about insufficient specialised commissioning to maintain patient engagement with hepatitis B services after opt-out screening.
Response (British Association for the study of the Liver): • The British Association for the Study of the Liver (BASL) and British Viral Hepatitis Group (BVHG) will incorporate the risks of hepatitis B reactivation and its prevention and management … (AI summary)
Overdue
Select committee recommendations(355)— showing 50 strongest matches
#5 —
Recommendation: Given the increasing volatility in food supplies, not just due to extreme weather, but also due to the recent geopolitical and health crises we have experienced, the Government should publish its food security report annually rather than every three years …
Response attribution not verified
#13 —
Recommendation: The Government must answer a range of outstanding questions in relation to the Joint Biosecurity Centre, including: the Government’s assessment of the benefits of establishing such a Centre for all four nations, how the devolved administrations will contribute and who …
Response attribution not verified
#12 —
Recommendation: The concept of the Joint Biosecurity Centre has been broadly welcomed by the witnesses we heard from, particularly the opportunity for the sharing and development of data sets. However, some questions around the role of the Centre remain, particularly how …
Response attribution not verified
#2 —
Recommendation: We are deeply concerned that there was so little early access to testing for Covid-19 for asylum seekers housed in shared facilities, whether IA or dispersal, given the higher risk of spreading infection in accommodation where it is often difficult …
Response attribution not verified
#21 —
Recommendation: While there have been some outbreaks in meat and poultry processing plants in England and Wales, these have been in the minority, which is a testament to the efforts of the industry to keep workers safe. Further investigations should be …
Response attribution not verified
#54 —
Recommendation: Keeping measures in place while closely monitoring travel corridors and other exceptions will be important to ensure that the UK does not reimport unmanageable levels of COVID-19. This is particularly important when there is doubt about the affordability—both economically, and …
Response attribution not verified
#52 —
Recommendation: Given the widespread concern about the potential for a second wave, and for a rising number of infections toward and during winter, it is likely that some form of border quarantine mechanism will be required for the foreseeable future to …
Response attribution not verified
#40 —
Recommendation: The creation of a Joint Biosecurity Centre ought to represent a step forward in the management of the pandemic, establishing clear responsibility for regular surveillance of travel risks from different countries and publishing clear and transparent analysis, including of international …
Response attribution not verified
#35 —
Recommendation: Given the surge in confirmed COVID-19 cases in mainland Spain and the clear and rising risk of increasing numbers of people returning to the UK with COVID-19, a precautionary approach including quarantine for returning travellers is the right one. As …
Response attribution not verified
#34 —
Recommendation: We welcome the Government’s commitment regularly to review its border quarantine regulations. The move to weekly and daily reviews of travel corridors is welcome as three-weekly reviews were not sufficiently frequent. Far more frequent review appropriately reflects the agility required …
Response attribution not verified
#24 —
Recommendation: It is deeply concerning that the Government is not able to provide any estimates that were produced at any point of the cardinal number of imported cases during March. The Home Office should have requested advice on the estimated number …
Response attribution not verified
#20 —
Recommendation: We also do not accept the Home Office’s suggestion that no measures were needed after 13 March because imported cases made up only 0.5% of total UK infections. That figure was not calculated until 22 March by which time a …
Response attribution not verified
#12 —
Recommendation: It is now apparent that many more COVID-19 cases were imported to the UK from Europe in mid-March than was estimated at the time, when, with the exception of Italy, the focus remained largely on potential importations of the virus …
Response attribution not verified
#8 —
Recommendation: We recognise the difficulties faced by the Government in considering temperature checks, screening or testing at the border, and we also recognise the limited UK testing capacity at that time. However, given the success of targeted COVID-19 testing on arrivals …
Response attribution not verified
#6 —
Recommendation: However, the failure to advise people travelling or returning from Spain in particular to self-isolate for 14 days (in line with category 1) or, at the very least, to monitor symptoms and call NHS 111 (in line with category 2) …
Response attribution not verified
#19 —
Recommendation: We call on the Government to throw its diplomatic weight behind the global community in investing in public health systems in developing countries; ensuring that testing, treatment and a vaccine when developed is made as widely available Economic impact of …
Response attribution not verified
#9 —
Recommendation: Scottish exports make a major contribution to the Scottish economy and the risks to those key export sectors ought to be a major concern of both the UK and Scottish Governments. We have heard about the huge reduction in exports …
Response attribution not verified
#18 —
Recommendation: We are satisfied that the science advice informing the Government has drawn upon some of the best expertise that the UK—and indeed the world—has to offer. We acknowledge the initial dominance of modelling expertise on SAGE and believe this is …
Response attribution not verified
#1 —
Recommendation: The consequences of another widespread outbreak of a zoonotic disease of similar lethality would be catastrophic. Covid-19 must therefore be treated as a wake-up call. The factors which appear to be increasing the incidence of such diseases must be thoroughly …
Response attribution not verified
#4 —
Recommendation: The introduction of rapid-results testing was supposed to be a ‘gamechanger’ but confusion persists over why and how it should be used in different community settings. Around one-third of people who have coronavirus are asymptomatic. There is now a widespread …
Response attribution not verified
#7 —
Recommendation: We are concerned that the UK’s reduced access to European health networks could undermine the UK and European response to future disease outbreaks. We recommend that the Government builds structured permanent cooperation with the European Centre for Disease Prevention and …
Response attribution not verified
#5 —
Recommendation: Without a full and transparent investigation into the origins of covid-19, we are at greater risk of a disastrous new outbreak. By impeding efforts to trace the origins of the virus, Beijing is endangering its own population along with the …
Response attribution not verified
#173 —
Recommendation: The consequences of this initial failure were profound. Testing not only allowed individuals to be identified who had covid-19—and were infectious—but test results for an invisible virus were the only way to be able to accurately monitor the incidence and …
Response attribution not verified
#162 —
Recommendation: The Government, via the World Health Organisation, should make the case for an international standard of reporting covid-19 deaths and a framework for reporting disease related deaths for future pandemics. 60 Coronavirus: lessons learned to date 4 Testing and contact …
Response attribution not verified
#137 —
Recommendation: Due to the much higher transmissibility of the Alpha variant, in the absence of a test, trace and isolate system capable of arresting the spread of the virus, a circuit-breaker in September and an earlier, more stringent lockdown, would likely …
Response attribution not verified
#136 —
Recommendation: The second wave of the pandemic was more numerous in terms of hospital admissions and deaths than the first wave. It peaked on 8 January 2021 with 68,053 new infections per day reported in the UK,214 and on 20 January …
Response attribution not verified
#134 —
Recommendation: Following genomic sequencing, PHE found that the Alpha variant first appeared in Kent in September 2020 and rapidly became the dominant variant in Kent, and subsequently, the rest of England.207 The new variant was first brought to the attention of …
Response attribution not verified
#173 —
Recommendation: The consequences of this initial failure were profound. Testing not only allowed individuals to be identified who had covid-19—and were infectious—but test results for an invisible virus were the only way to be able to accurately monitor the incidence and …
Response attribution not verified
#162 —
Recommendation: The Government, via the World Health Organisation, should make the case for an international standard of reporting covid-19 deaths and a framework for reporting disease related deaths for future pandemics. 60 Coronavirus: lessons learned to date 4 Testing and contact …
Response attribution not verified
#137 —
Recommendation: Due to the much higher transmissibility of the Alpha variant, in the absence of a test, trace and isolate system capable of arresting the spread of the virus, a circuit-breaker in September and an earlier, more stringent lockdown, would likely …
Response attribution not verified
#136 —
Recommendation: The second wave of the pandemic was more numerous in terms of hospital admissions and deaths than the first wave. It peaked on 8 January 2021 with 68,053 new infections per day reported in the UK,214 and on 20 January …
Response attribution not verified
#134 —
Recommendation: Following genomic sequencing, PHE found that the Alpha variant first appeared in Kent in September 2020 and rapidly became the dominant variant in Kent, and subsequently, the rest of England.207 The new variant was first brought to the attention of …
Response attribution not verified
#1 — Provide funding for diagnostic facilities and ensure focus on multiple vaccine technologies for pandemics
Recommendation: Should our successor Committee wish to further explore emerging diseases and learnings from covid-19, we recommend: • Funding should be made available for diagnostic facilities to uphold contracts, maintain equipment, and run laboratories to allow for fast and accurate diagnoses …
Response status not verified
#14 — Increasing threat from highly resistant Gram-negative infections with limited treatment options
Recommendation: Dr Partridge told us that there is also an increasing threat in the UK from strains of pathogens which cause Gram-negative infections that are more likely to be resistant and more likely to result in the death of the patient. …
Response attribution not verified
#13 — Establish a taskforce for illegal imports of animal products, led by the Minister for Biosecurity.
Recommendation: A taskforce for illegal imports of animal products should be established by November 2025, led by the Minister for Biosecurity, to provide oversight of the strategy’s design and implementation and to drive improvements. The taskforce should at least include the …
Response attribution not verified
#10 — Defra lacks comprehensive strategy and convincing plan to prevent animal diseases and tackle POAO smuggling.
Recommendation: The Committee supports the Government’s commitment to “do whatever it takes to protect British farmers from foot and mouth”. The Committee welcomes efforts made so far, but concludes that there is more that Defra 36 could and should be doing …
Response attribution not verified
#9 — Design a strategy to reduce demand for illegally imported products and engage communities.
Recommendation: Defra should work with the Food Standards Agency and Food Standards Scotland to design a strategy to reduce demand for illegally imported products. Defra must further consider how to engage with Eastern European communities in Great Britain to raise awareness …
Response attribution not verified
#7 — Consult on and introduce a permanent, straightforward personal import policy for EU products.
Recommendation: Defra must consult on a permanent personal import policy for the EU by April 2026. It should prioritise safeguarding British farms and should be straightforward enough to be understood by travellers and to be enforced. The current temporary ban on …
Response attribution not verified
#6 — Defra's approach to EU personal imports has been lax, reactive, and complicated.
Recommendation: Under successive governments, Defra’s approach to personal imports from the EU since 2021 has been unnecessarily lax, too reactive and overly complicated. Temporary personal import rules create confusion for travellers, uncertainty for farmers, and difficulty for enforcement professionals. (Conclusion, Paragraph …
Response attribution not verified
#5 — Compel travel operators and scale up Defra communications including a digital import tool.
Recommendation: Travel operators should be legally compelled to inform travellers of the rules for personal imports from the EU into GB. Defra must immediately scale up its communications to the public about personal import rules and reach a much broader audience. …
Response attribution not verified
#3 — Commission risk assessment and publish quarterly data on illegal animal product imports.
Recommendation: Defra should commission a risk assessment of the type published by the Veterinary Laboratories Agency in 2004 for the import of contaminated meat and meat products into Great Britain and subsequent exposure of livestock. It should model the probable amount …
Response attribution not verified
#2 — Greater understanding and transparency needed on illegal animal product imports.
Recommendation: Consumers deserve confidence that the food they are buying is safe and meets high welfare standards, and British farmers should not be undercut by cheap, poor quality animal products. We need to understand more about the nature and scale of …
Response attribution not verified
#1 — Animal diseases pose a national security risk and threaten farmer wellbeing.
Recommendation: Animal disease threats like foot and mouth disease and African swine fever are a national security issue and must be understood as such across Government. Although it is not possible to prevent all contaminated animal products entering Great Britain, the …
Response attribution not verified
#10 — Require confirmation of disease commodity code database and a 24/7 IPAFFS update team.
Recommendation: In response to this Report, the Government should confirm that it has produced a list of pre-identified commodity codes for the top five notifiable diseases and provide a copy of this database containing the commodity codes in question to the …
Response attribution not verified
#29 — Public awareness of personal import rules is overestimated and survey methods are inadequate.
Recommendation: Relying on the goodwill of EU travel operators to communicate personal import rules is not an acceptable approach. Defra has acknowledged that its current survey methods make it difficult to assess public awareness of personal import restrictions, and it has …
Response attribution not verified
#26 — Develop strategy by June 2026 to reduce demand for illegally imported animal products
Recommendation: Defra must not wait until SPS negotiations are concluded before developing a strategy to reduce demand for illegally imported animal products. We reiterate the recommendation made in our previous report on this topic that the Government, by June 2026, should …
Response attribution not verified
#25 — SPS agreement lacks mechanisms to prevent criminal activity from illegal meat imports
Recommendation: Both the EU and the UK are exposed to biosecurity risks from illegal meat imports. Although future access to EU data systems and intelligence within a common SPS area could support British border enforcement efforts, there is nothing within an …
Response attribution not verified
#24 — Ensure Great Britain maintains robust risk-based controls against serious plant and animal diseases
Recommendation: The Government must ensure that Great Britain is able to maintain risk- based controls to protect against serious plant and animal disease threats. This includes the continuation of robust import controls on plants that can host the bacterial disease caused …
Response attribution not verified
#23 — Great Britain must retain ability to apply robust biosecurity measures against European diseases
Recommendation: Maintaining Great Britain’s biosecurity is vital. Britain’s geography provides natural protection from many plant and animal health threats. Any future SPS agreement will require adjustments to existing border controls, but it remains essential that GB retains the ability to apply …
Response attribution not verified
#22 — Current UK animal tracing systems are fragmented, old, and fragile
Recommendation: Livestock movements in England are significant. For example, there are around 20 million movements of sheep to or from different farms, livestock markets, collection centres, and to abattoirs each year. These movements increase the risk of spreading disease. Being able …
Response attribution not verified
HSSIB safety recommendations(2)
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to analyse data collated on asymptomatic staff infection rates to consider how this may impact on mitigation strategies to reduce the risk of nosocomial transmission.
Safety Observation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHS England and NHS Improvement: supports additional capacity for testing for NHS patients and staff (Pillar 1 testing) facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies …
Safety Recommendation
CQC inspection actions(15)
Diana Princess of Wales Hospital
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with trust and national guidance
Must Do
Clatterbridge Hospital
The services should continue to develop its surveillance of surgical site infections.
Should Do
Dorset County Hospital
Theserviceshouldmonitorinfectionrates.
Should Do
Royal Lancaster Infirmary
The service should continue to monitor and review antimicrobial stewardship and prescribing in sepsis.
Should Do
Royal Lancaster Infirmary
The service must ensure hand gel expiry dates are compliant and the environment is visibly clean with cleaning schedules appropriately completed.
Must Do
Furness General Hospital
The service must ensure hand gel expiry dates are compliant and the environment is visibly clean with cleaning schedules appropriately completed.
Must Do
Cumberland Infirmary
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with national guidance. This includes, but is not limited to, cleaning substances subject …
Must Do
Clatterbridge Hospital
The services should improve the standard of infection, prevention, control and cleanliness within it.
Should Do
Clatterbridge Hospital
The services should ensure that staff adhere to infection prevention control practices.
Should Do
Clatterbridge Hospital
The service must ensure that it reduces its number of surgical site infections.
Must Do
Clatterbridge Hospital
The service must ensure all staff follow infection prevention and control measures and implement effective processes to prevent and control outbreaks of infection.
Must Do
The Sidings Medical Practice
Continue their work to improve uptake of childhood immunisations and cervical screening.
Should Do
Queens Hospital
Ensure infection prevention control audits regularly are completed.
Must Do
Moorcroft Medical Centre
Continue to improve the uptake of childhood immunisations.
Should Do
Block Lane Surgery
Improve their cervical screening data.
Should Do
PPO death in custody recommendations(1)
NAO audit recommendations(15)
The rollout of the COVID-19 vaccination programme in England
NHSE&I and UKHSA, working with local and national partners, should seek new ways to increase uptake for groups where rates are lower than for the rest of the population, and should also evaluate what has worked well to date and …
Accepted
Investigation into how government is addressing antimicrobial resistance
The government should consider how the results of the new NHS antibiotic subscription model will be tracked, evaluated and made public, including any effects on the research and development of new drugs.
Accepted
Investigation into how government is addressing antimicrobial resistance
The government should consider whether targets for no increase in a range of human infections are stretching enough to make a contribution to the vision of reducing the burden of infection.
Accepted
Investigation into how government is addressing antimicrobial resistance
The government should consider how delivery of its current targets and commitments can be more successful than in NAP19?24, including through the use of strengthened performance monitoring and deadlines for implementation
Accepted
The rollout of the COVID-19 vaccination programme in England
DHSC and BEIS, working with the Taskforce, NHSE&I and UKHSA, should set out a clear plan to identify and reach a sustainable future model for COVID-19 vaccination, clearly setting out responsibilities at national and local level, based on a considered …
Accepted
The rollout of the COVID-19 vaccination programme in England
Taking into account its ongoing procurements, the Taskforce should set out a clear strategy for how it will maintain flexibility to respond to the continuing uncertainties of the pandemic, including the emergence of new variants, and changes in demand. This …
Accepted
The rollout of the COVID-19 vaccination programme in England
The Taskforce, NHSE&I and UKHSA, working with local partners, should set out a clear strategy for managing surpluses and wastage in 2022 and review the overall expected wastage, ensuring they learn lessons from the write-offs required for AstraZeneca.
Accepted
Ensuring food safety standards
Within six months of the UK leaving the EU, the FSA should start to work closely with the other departments in the regulatory system to evaluate the medium- and longer-term impacts of EU exit on the capacity of the food …
Accepted
Ensuring food safety standards
The FSA should address gaps in outcome-based measures and targets for assessing compliance with food safety and composition standards. It should press ahead with developing indicators for assessing the performance of local authorities in providing assurance that food businesses are …
Accepted
Ensuring food safety standards
The FSA should establish the role that sampling plays in reducing risks to consumers. As part of its work on developing a sampling strategy, it should assess what level of and approach to sampling is needed to provide assurance that …
Accepted
Investigation into how government is addressing antimicrobial resistance
The government should consider what the UK?s aquatic environment is currently contributing to rising AMR, particularly wastewater treatment and spills, and, as a result, whether new commitments or targets are needed in this area.
Accepted
Immigration enforcement
b) Expand its knowledge of the scale of irregular migration and the barriers it faces in tackling this. There are opportunities for the Department to build on its demand planning work, external research and other estimates of hidden activity across …
Accepted
Ensuring food safety standards
The organisations in the food regulation system should work together to assess government’s appetite for risk and to take decisions on the level of funding required to ensure that food is safe to eat and what it says it is. …
Accepted
Ensuring food safety standards
The FSA should address gaps in the enforcement powers, including those available to the National Food Crime Unit. Given the additional funding that has been directed towards the National Food Crime Unit, the FSA should make firm plans to provide …
Accepted
Ensuring food safety standards
The FSA should press ahead with its ambition to introduce mandatory display of hygiene ratings in food businesses in England. Recognising the requirement for legislation and current demands on Parliamentary time, the FSA should aim to do this within an …
Accepted
IMB annual reports(5)
Heathrow and City airports Short Term Holding Facilities (2021)
The reporting period was significantly impacted by the Covid-19 pandemic, leading to concerns about infection control, longer detainee stays, and increased waiting times. Key issues included slow implementation of effective Covid-19 measures, inability for detainees to access personal medication, and inadequate hygiene and family facilities in some terminals. Despite these challenges, Detention Custody Officers were observed to be largely kind and courteous.
PRISON
Key concerns
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
This report presents the findings of the Independent Monitoring Board at Glasgow, Edinburgh and Larne House Short Term Holding Facilities for 2020-2021. Overall, detainees are treated respectfully by staff, but the Covid-19 pandemic exposed significant issues, including reactive Home Office guidance, inadequate social distancing, and delayed infrastructure improvements. Key concerns persist regarding healthcare provision (medication administration), disability access, and facility suitability, with numerous recommendations made to address these shortcomings.
PRISON
Key concerns
Dover Short Term Holding Facilities (2021)
The Dover Independent Monitoring Board raises urgent concerns about the continuing and worsening conditions at Tug Haven, Kent Intake Unit (KIU), and Frontier House. Facilities are severely overcrowded, leading to migrants, including vulnerable children, sleeping in unheated and unsanitary tents. Significant issues with undetected injuries, inadequate medical screening, and insufficient healthcare staffing are highlighted, along with staff demoralisation and safety incidents stemming from the challenging environment.
PRISON
Key concerns
Heathrow Immigration Removal Centre (2021)
The IMB report for Heathrow IRC (Jan-Dec 2021) identifies generally safe conditions but raises serious concerns regarding the management of Short-term Holding Facility (STHF) detainees, particularly South Coast Arrivals (SCAs), which compromised safety and humane treatment. Significant issues include the inappropriate detention of individuals with severe mental health needs, a critical lack of engagement from the Detention Engagement Team (DET), and unacceptably prolonged detention periods for many. The Board calls for urgent policy reviews, capital investment in infrastructure, and improved communication and service provision to address these systemic problems.
IRC
Key concerns
Forest Bank (2021)
HMP Forest Bank, a Category B male prison, faced a challenging year (Nov 2020-Oct 2021) marked by the Covid-19 pandemic, staff shortages, and a transition to a reception prison. Despite these challenges, the Board noted significant improvements in safety, accommodation, and security, driven by a new management team and a proactive approach to Covid containment. Key positive developments include a new employment hub for resettlement and exceptional catering, while concerns remain regarding property handling, organised crime group activity due to the new reception status, and the long-term sustainability of improvements given staff shortages.
PRISON
Key concerns
IMB individual recommendations(24)
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That, with regard to Covid-19, an assessment is made of the capacity of the EDI and GLA HRs to provide safe distances between detainees and staff, and that maximum numbers are clearly displayed at the entrance to each HR.
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
As a first step, the temperature should be taken of those detainees who have not been tested for Covid-19 as they are accepted into the HRs. We would then expect that appropriate measures be taken to isolate those showing a high temperature.
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That, in light of the experiences learned from the Covid-19 pandemic, detailed epidemic/infection control plans, with actions, are shared with the IMB GEL. This practice should be adopted in any further outbreaks of contagious illnesses.
Home Office
Parc (2021)
Procedures should be in place, during any form of pandemic, whereby prisoners transferring are tested and, where found to be positive, isolated prior to a transfer to another establishment taking place. This should be a mandatory action and not left to individual prisons to make a decision.
HMPPS
Implemented
Parc (2021)
The supply of vaccines to protect prisoners should be continuous, without gaps in supply from PHW, which made the risk of transmission greater in a prison environment.
Other
Implemented
Maidstone (2021)
Urgently review prisoner transfer and testing processes so that prisoners are not transferred until they have first been properly COVID tested.
HMPPS
In Progress
Lowdham Grange (2021)
Implement national procedures to test prisoners for COVID19 prior to transfer/travel to new establishments so as to reduce risks to prisoners and staff in the receiving prisons.
HMPPS
Implemented
Tinsley House IRC (2020)
to reconsider its current policy of not Covid-19 testing detainees on arrival at Tinsley House STHF, or thereafter during their period of detention.
Home Office
Isis (2020)
return to a full regime as soon as conditions around the pandemic and the advice of PHE indicate that it is safe to do so
HMPPS
In Progress
Cardiff (2020)
Therefore, we would ask what consideration has been given to easing these regimes, dependent on prison and community levels of infection?
HMPPS
In Progress
Leicester (2021)
Would the minister consider whether a special case could be made for all prisoners and staff at Leicester to receive priority vaccinations, to redress this imbalance and to allow relaxations to proceed fairly?
Ministry of Justice
Implemented
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That wall mounted sanitisers be fitted at each of the airport HR entrances.
Home Office
Bristol (2021)
Why was Covid-19 vaccination not carried out as a pan-prison programme to protect vulnerable prisoners in crowded environments and also staff, many of whom should be considered equal to care staff in their role? Is this being reviewed for the future?
Ministry of Justice
Forest Bank (2020)
Can the Minister comment on the exceptional partnership work conducted by HMP Forest Bank, HMPPS and Public Health England to control the Covid 19 outbreak and to keep staff, residents, and visitors safe and what will happen after the pandemic?
Ministry of Justice
In Progress
Norwich (2021)
Will HMPPS explain why the prisoners in L wing were not treated like care-home residents in terms of priority for Covid vaccine when they are equally at 'higher clinical risk of severe disease and mortality' (Joint Committee on Vaccination and Immunisation (JCVI) 26 January 2021), and their environment is comparable?
HMPPS
Norwich (2021)
When expert opinion suggests that prisons should have been chosen for vaccine prioritisation, will the Minister explain why prisons were not selected as a priority group?
Ministry of Justice
Noted
Heathrow and City airports Short Term Holding Facilities (2021)
The Home Office and detention contractor should ensure that their respective policies and guidance on pandemic precautions are strictly adhered to by staff, visitors and, as far as is practicable, by detainees.
Home Office
East Sutton Park (2021)
To continue with the prompt and careful steps taken to combat Covid-19.
Governor / Director
Downview (2021)
Support prisons receiving special vaccination status, consistent with the recognition of prisons as ‘high risk, closed environments’.
Ministry of Justice
Noted
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Home Office should ensure that Heathrow Airport Limited (HAL) make the necessary fitment changes to ensure that the showers in all the terminals are not subject to frequent closure due to concern about legionella bacteria (para. 3.9).
Home Office
Parc (2021)
Should there be further need for vaccinations for Covid-19 or any other such pandemic, operational staff within the Prison Service should be treated as a priority group in order to protect the integrity of the service. There was, at one stage, capacity within Cwm Taf Local Health Board to support vaccinations, but this was withdrawn by Public Health Wales (PHW).
Other
Rejected
Tinsley House IRC (2020)
to reconsider its policy of allowing room sharing at Tinsley House STHF by multiples of detainees during the currency of the pandemic, simply because they may have spent time together in small boats or on coaches en route to the centre.
Home Office
Garth (2021)
Maintain a secure and safe environment through the remainder of the Covid pandemic.
Governor / Director
Deerbolt (2021)
Are there lessons to be learnt from the Covid-19 pandemic in regards to the benefits of restrictions on the regime?
Ministry of Justice
Noted
National patient safety alerts(1)
Health investigations(1)
Independent reviews(5)
O'Neill AMR Review — Rec 4
Improve global surveillance of drug resistance in humans and animals 4.1 WHO to provide global leadership and coordination to efforts – supported from governments, regional organisations, and philanthropic organisations – to establish a global surveillance system to monitor the emergence and spread of drug-resistant infections. 4.2 National governments/regulators and globally-representative …
Health & Social Care
O'Neill AMR Review — Rec 3
Reduce unnecessary use of antimicrobials in agriculture and their dissemination into the environment 3.1 The G20 and UN, with input from the WHO, FAO and OIE, should lead urgent global efforts to improve the collection and use of surveillance data regarding the use of antibiotics in agriculture, and the emergence …
Health & Social Care
Cunliffe Water Commission — Rec 13
Recommendation 13: Future water monitoring programs should be reviewed and adequately resourced, to accurately reflect the state of the environment.
Other
Cunliffe Water Commission — Rec 12
Recommendation 12: To facilitate a robust assessment of how public health can be effectively incorporated into a new water framework, the UK and Welsh governments should establish taskforces led by the Chief Medical Officers of England and Wales to review the incorporation of public health better into the legislative framework …
Other
Cunliffe Water Commission — Rec 11
Recommendation 11: The UK and Welsh governments should consult on reforms to the WFD Regulations, including broadening the scope to include public health outcomes.
Other
PHSO casework decisions(5)
P-004401 — East Suffolk and North Essex NHS Foundation Trust
Mrs D alleged the Trust failed to test Mr D for flu, leading to a missed AHLE diagnosis and incorrect treatment, potentially shortening his life.
NHS in England
Partly Upheld
Dec 2025
P-002514 — Milton Keynes University Hospital NHS Foundation Trust
Ms C complained Trust staff delayed diagnosing and providing correct treatment for her father's COVID-19 illness in December 2020, which she believes led to his death.
NHS in England
Mar 2024
P-004063 — Portsmouth Hospitals University NHS Trust
Mrs N complained the Trust failed to timely diagnose and treat her husband's colitis caused by C-DIFF, which she believes caused his death.
NHS in England
Sep 2025
P-004379 — UK Health Security Agency
Mr R complained UKHSA failed to inform him of contact-tracing deadlines, did not offer a representative, unfairly marked him 'non-compliant', and handled his complaint poorly, causing financial loss and stress.
UK Government
Not Upheld
Nov 2025
P-002263 — Mid and South Essex NHS Foundation Trust
A patient complained about COVID-19 care, including signing an unreadable consent form, an oxygen machine running out of water, lack of an OT appointment, and adverse effects from steroid treatment.
NHS in England
Oct 2023
LGO / SPSO decisions(38)
PSOW-202006082 — Cardiff and Vale University Health Board
13. Mrs X complained about the Health Board’s refusal to remove a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) form from her medical records. She explained that she felt worried, particularly if it became necessary for her to be readmitted into hospital. The Ombudsman found that the decision about the appropriateness …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-202204424 — Hywel Dda University Health Board
Mrs X complained about her husband’s hospital discharge in April 2022; she said that he was unwell with COVID-19, which she then contracted. The assessment found that, although the Health Board had responded to the complaint, it had not fully addressed the issues raised around the discharge. The Ombudsman sought …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202104785 — Cwm Taf Morgannwg University Health Board
Ms L complained that the Health Board failed to take adequate measures to protect her husband, a patient at increased risk of severe illness from COVID-19, from contracting the disease. Ms L also complained that the Health Board failed to carry out a full and thorough investigation of her complaint …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202304628 — Aneurin Bevan University Health Board
Mrs A complained about hospital treatment provided by Aneurin Bevan University Health Board to her father, Mr B, between February and April 2020. The Ombudsman’s investigation considered the following questions: a) Were appropriate infection control measures put in place to protect Mr B from contracting COVID-19? b) Was the decision …
PSOW (Public Services Om…
Health
Upheld
Jul 2024
PSOW-202104936 — Cwm Taf Morgannwg University Health Board
Mrs A complained to the Ombudsman that when her mother, Mrs B was admitted to the Emergency Department (“the ED”) of the Princess of Wales Hospital (“the Hospital”), they had failed to assess and investigate her symptoms which were indicative of a stroke sufficiently quickly. She considered that this failure …
PSOW (Public Services Om…
Health
Upheld
Aug 2023
PSOW-202303509 — Cardiff and Vale University Health Board
Mr B complained that the Health Board had not appropriately considered his family member’s case as part of its nosocomial review process. In particular, Mr B considered that his family member was placed on a “covid ward” and this was not addressed in the Health Board’s decision letter. The investigation …
PSOW (Public Services Om…
Health
Mar 2024
21-000-686 — London Borough of Barnet
Summary: Ms D complains on her own behalf and on behalf of her late mother, Mrs J, about the care provided to Mrs J while she was resident in an extra care housing placement during the first COVID-19 lockdown. We have found no fault in the care provided to Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-010-517a — Gloucestershire Clinical Commissioning Group (20 010 517a)
Summary: Mrs Y and Ms Z complained about funding for their mother, Mrs X’s, residential care and the response to an injury to Mrs X’s hand. We have upheld the complaints against the Council and recommended remedies. We have not upheld the complaint against the NHS Clinical Commissioning Group. The …
LGO (Local Government & …
Health
Not Upheld
Feb 2022
20-010-517 — Gloucestershire County Council
Summary: Mrs Y and Ms Z complained about funding for their mother, Mrs X’s, residential care and the response to an injury to Mrs X’s hand. We have upheld the complaints against the Council and recommended remedies. We have not upheld the complaint against the NHS Clinical Commissioning Group. The …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-009-170 — Lincolnshire County Council
Summary: Mrs A complains about the care of her mother, Mrs B at a care home. She has also complained about a council’s safeguarding enquiries. We found fault in relation to the Home’s lack of mask wearing. We did not find fault with the other issues in this complaint.
LGO (Local Government & …
Adult Care Services
Not Upheld
May 2022
21-014-447 — Plymouth City Council
Summary: Miss X complains about the care her grandmother, Mrs Y, received at Greenacres Care Centre, where the Council placed her for respite care. The Council accepts there were examples of poor care and poor communication with Mrs Y’s family. It needs to apologise to her family and make a …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
21-009-369 — North East Lincolnshire Council
Summary: Miss X complains the Council’s blanket ban on care home residents visiting people outside a care home when there were cases of COVID-19 in the care home prevented her father from visiting her on a number of occasions since September 2021. Based on the evidence seen so far, the …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-007-147 — Gloucestershire County Council
Summary: We will not investigate Mr X’s complaint about alleged negligence by the Council causing personal injury to members of his family. This is because it would be reasonable for Mr X to take the matter to court.
LGO (Local Government & …
Other Categories
Sep 2022
201603268 — Scottish Borders Council
Mr C complained about the council's handling of assessments of his business following the imposition of a remedial action notice under the Food Hygiene (Scotland) Regulations 2006. He also complained that the council incorrectly registered his business and failed to correct this within a reasonable time-frame. The council inspected Mr …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2017
PSOW-202100872 — Natural Resources Wales
Mr X complained that Natural Resources Wales (“NRW”) had not responded to the complaint he made to it in 2019 regarding inadequate dog control signs and access by motor vehicles in forest areas near Mr X. The Health Board agreed to undertake the following in settlement of Mr X’s complaint: …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-202203313 — Betsi Cadwaladr University Health Board
Mrs G complained that the Health Board had not adequately investigated her complaint about how her late father, Mr S, contracted COVID-19 before his death at Wrexham Maelor Hospital in August 2020. Under the Putting Things Right (“PTR”) complaints process, the Health Board was required to explain whether a breach …
PSOW (Public Services Om…
Health
Oct 2022
PSOW-202206031 — Betsi Cadwaladr University Health Board
Mrs A complained on behalf of her late husband, Mr B, about the treatment and care provided by the Health Board on his admission to hospital in September 2020. Mrs A said that the Health Board failed to protect Mr B from contracting COVID-19 while in hospital and to undertake …
PSOW (Public Services Om…
Health
Jan 2023
PSOW-202205762 — Swansea Bay University Health Board
Mr A complained that he was not informed of his positive COVID-19 test or provided with appropriate discharge advice about self-isoaltion. The Ombudsman was concerned that Swansea Bay University Health Board (“the Health Board”) could not satisfactorily evidence whether Mr A was informed about the positive test or provided with …
PSOW (Public Services Om…
Health
Mar 2023
PSOW-202207305 — Swansea Bay University Health Board
Mr A complained about whether the Health Board appropriately considered his mother’s case as part of its nosocomial review process (a process set up by Welsh Government for Health Boards to review cases where a patient may have contracted Covid-19 in hospital) and in line with the National Framework and …
PSOW (Public Services Om…
Health
Oct 2023
21-002-898 — East Sussex County Council
Summary: We upheld a complaint from Miss X on behalf of her son Mr Y about the Council’s handling of his special educational needs provision. The Council failed to secure some of the therapeutic support in Mr Y’s plan. The Council agreed to apologise to Mr Y, make a payment …
LGO (Local Government & …
Education
Upheld
Apr 2022
21-017-366 — Stockport Metropolitan Borough Council
Summary: Ms Z complained the Council wrongly charged her mother, Mrs X, for care home fees, took too long to assess her and communicated poorly. The Council delayed significantly in assessing Mrs X’s care needs. This has caused Ms Z uncertainty about whether Mrs X is in the most appropriate …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
21-017-300 — Cornwall Council
Summary: Mr X complained the Council awarded his business a COVID-19 business grant but later notified him it had been paid in error and demanded repayment. The timing of the recovery decision meant Mr X lost the opportunity to apply for other grant funding which he may have been eligible …
LGO (Local Government & …
Benefits And Tax
Upheld
Jun 2022
21-009-708 — Sefton Metropolitan Borough Council
Summary: We upheld Ms X’s complaint about a lack of hydrotherapy for her son, Y. The Council accepted there was fault in the way it handled Y’s hydrotherapy provision and offered a remedy. We identified further injustice to Ms X and Y in the form of distress and the Council …
LGO (Local Government & …
Education
Upheld
Jun 2022
21-014-087 — Calderdale Metropolitan Borough Council
Summary: We have discontinued our investigation into this complaint, about the Council’s private hire driver licensing process during the COVID-19 pandemic. This is because the Council has already addressed the main issues and further investigation will not achieve anything significant.
LGO (Local Government & …
Environment And Regulation
Not Upheld
Jun 2022
21-016-909 — Tameside Metropolitan Borough Council
Summary: Mr X complains the Council failed to deal properly with the charges for his mother’s care,
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
22-004-373 — Wirral Metropolitan Borough Council
Summary: Mr X complained about charges for his mother’s residential care. Mr X also complained failings by the Council’s care provider led to his mother catching COVID-19 and passing away. We will not investigate Mr X’s complaint. This is because there is not enough evidence of fault in how the …
LGO (Local Government & …
Adult Care Services
Jul 2022
21-019-063 — Shropshire Council
Summary: We found no fault by a Council and ICB with regards to how they assessed Mrs Y’s needs following her discharge from hospital. However, we found fault with the Council’s complaint response which incorrectly advised Mrs Y’s son that a Continuing Healthcare Checklist had been completed when it had …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-007-136 — Derbyshire County Council
Summary: We will not investigate this complaint about the placement of Mrs Y’s room in a care home. We could not come to sound conclusions about the care provider’s actions and whether Mrs Y experienced injustice due to the placement of her room. We could not achieve a meaningful remedy …
LGO (Local Government & …
Adult Care Services
Sep 2022
PSOW-202206255 — Cardiff and Vale University Health Board
Ms A complained about the treatment of her late sister, Mrs B, who contracted Covid-19 after being admitted to a hospital within the Health Board for an unrelated condition and sadly died. Ms A had received an initial complaint response under the Putting Things Right (“PTR”) process, but posed further …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202203473 — Cardiff and Vale University Health Board
Ms A complained about the treatment of her late sister, Mrs B, who contracted Covid-19 after being admitted to a hospital within the Health Board for an unrelated condition and sadly died. Ms A had received an initial complaint response under the Putting Things Right (“PTR”) process, but posed further …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202300621 — Ceredigion County Council
Mr T complained that Ceredigion County Council failed to acknowledge or provide a response to his complaint about trees. The Ombudsman decided that the Council had failed to acknowledge any of Mr T’s letters and had not logged his concerns as a complaint. She said that this caused frustration and …
PSOW (Public Services Om…
Health
Jun 2023
21-007-938 — Trafford Council
Summary: We will not investigate Ms B’s complaint about the Council’s pest control service. This is because there is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Environment And Regulation
Jan 2022
22-005-135 — Liverpool City Council
Summary: Mr X complains the Council failed to deal properly with his mother’s placement in a care home since June 2020. It is too late to investigate much of Mr X’s complaint. Recent events do not support the claim of fault by the Council.
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
22-005-459 — Maidstone Grammar School For Girls
Summary: Mrs X complains that she was denied a fair school admission appeal hearing as she did not receive emails about her appeal so did not have the opportunity to submit further information to the appeal panel. There is no evidence of fault by the School.
LGO (Local Government & …
Education
Not Upheld
Oct 2022
22-004-098 — Stockton-on-Tees Borough Council
Summary: We will not investigate this complaint about the residential care provided to Mrs Y. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. It is unlikely we could add anything to the response the complainant’s have …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
23-020-388 — London Borough of Merton
Summary: We will not investigate this complaint about the Council’s response to Mr X’s report of food poisoning from business premises in its area. This is because we are unlikely to find evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Apr 2024
24-020-467 — North Yorkshire Council
Summary: We will not investigate Mrs X’s complaint about how the Council dealt with her reports of pollution. This is because there is insufficient evidence of fault causing her a significant injustice.
LGO (Local Government & …
Environment And Regulation
May 2025
25-003-239 — Somerset Council
Summary: We will not investigate this complaint about a food hygiene rating. This is because there is not enough evidence of fault or injustice to justify our involvement.
LGO (Local Government & …
Environment And Regulation
Aug 2025