Duty of Candour implementation
Identified shortcomings in the practical operation and implementation of duties of candour within healthcare systems.
Source spread
Where this theme appears
This theme appears across 18 independent accountability sources, so the source mix matters as much as the headline total.
83 inquiry recs
39 PFD reports
19 committee recs
33 CQC actions
3 ICIBI recs
1 PPO rec
1 PHSO rec
4 IMB recs
1 Scottish FAI
3 detention investigation recs
4 DHR recs
134 PHSO decisions
213 LGO/SPSO decisions
4 CQC enforcement actions
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(83)— showing 50 strongest matches
92 — Apologies to former child migrants
Recommendation: As we have set out in the institution-specific sections of the report, some institutions have still not apologised for their role in the child migration programmes. We recommend that they do so, as soon as possible. We recommend that they …
No response yet
R104 — Statutory duty of candour
Recommendation: A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all their dealings with service users and the public. (ii) Where …
No response yet
BRIS-34 — Ensure patients receive acknowledgement, explanation, and apology when care goes wrong
Recommendation: When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology.
Unknown
BRIS-33 — Establish a duty of candour for all NHS staff regarding adverse events
Recommendation: A duty of candour, meaning a duty to tell a patient if adverse events2 have occurred, must be recognised as owed by all those working in the NHS to patients.
Unknown
F184 — Enforcement by the Care Quality Commission
Recommendation: Observance of the duty should be policed by the Care Quality Commission, which should have powers in the last resort to prosecute in cases of serial non-compliance or serious and wilful deception. The Care Quality Commission should be supported by …
Gov response: Accepted. This is accepted in respect of the statutory duty of candour. This new duty will be a requirement for registration with the Care Quality Commission. In line with other registration requirements, Care Quality Commission …
Accepted
F183 — Criminal liability
Recommendation: It should be made a criminal offence for any registered medical practitioner, or nurse, or allied health professional or director of an authorised or registered healthcare organisation: Knowingly to obstruct another in the performance of these statutory duties; To provide …
Gov response: Not accepted, however we agree with the intention behind this recommendation. The duty of candour is a further drive towards openness and transparency. We have set out in the Care Bill that in future, as …
Not accepted
F182 — Statutory duty of openness and transparency
Recommendation: There should be a statutory duty on all directors of healthcare organisations to be truthful in any information given to a healthcare regulator or commissioner, either personally or on behalf of the organisation, where given in compliance with a statutory …
Gov response: Accepted. Subject to the passage of the Care Bill, a new criminal offence will be introduced applicable to care providers that supply or publish certain types of information which is false or misleading, where that …
Accepted
F181 — Enforcement of the duty Statutory duties of candour in relation to harm to patients
Recommendation: A statutory obligation should be imposed to observe a duty of candour: On healthcare providers who believe or suspect that treatment or care provided by it to a patient has caused death or serious injury to a patient to inform …
Gov response: Accepted in principle. As set out in recommendation 174, the Government will introduce an explicit duty of candour as a Care Quality Commission registration requirement. The duty would apply to health and adult social care …
Accepted in part
F178 — Implementation of the duty Ensuring consistency of obligations under the duty of openness transparency and …
Recommendation: The NHS Constitution should be revised to reflect the changes recommended with regard to a duty of openness, transparency and candour, and all organisations should review their contracts of employment, policies and guidance to ensure that, where relevant, they expressly …
Gov response: Accepted in principle. We agree that staff should be honest and open with patients, and The NHS Constitution already emphasises the importance of honesty and openness in its values and sections outlining staff responsibilities, rights …
Accepted in part
F177 — Openness in public statements
Recommendation: Any public statement made by a healthcare organisation about its performance must be truthful and not misleading by omission.
Gov response: Accepted. Accountability is a key leadership role and effectively means organisations operate effectively and with openness, transparency and candour at all times. The NHS Leadership Academy’s guide, The Healthy NHS Board 2013 – Principles for …
Accepted
F176 — Openness with regulators
Recommendation: Any statement made to a regulator or a commissioner in the course of its statutory duties must be completely truthful and not misleading by omission.
Gov response: Accepted. The Government’s response to the Inquiry, Patients First and Foremost reaffirmed a commitment to the values of openness, honesty and acceptance of challenge and when things go wrong to learn from and not conceal …
Accepted
F175 — Candour about harm
Recommendation: Full and truthful answers must be given to any question reasonably asked about his or her past or intended treatment by a patient (or, if deceased, to any lawfully entitled personal representative).
Gov response: Accepted. All regulated professionals through the principles that underpin their standards and codes of conduct are required to be open and transparent with patients in respect of discussions about treatment and care. As set out …
Accepted
F174 — Candour about harm
Recommendation: Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be …
Gov response: Accepted. The Secretary of State for Health legally required NHS England to insert a contractual duty of candour into the NHS Standard Contract in 2013–14. This means that NHS Trusts and Foundation Trusts are contractually …
Accepted
F173 — Principles of openness transparency and candour
Recommendation: Every healthcare organisation and everyone working for them must be honest, open and truthful in all their dealings with patients and the public, and organisational and personal interests must never be allowed to outweigh the duty to be honest, open …
Gov response: Accepted. Promoting honesty, openness and transparency, and instilling a culture that values compassion, dignity and the highest quality of care is one the key responsibilities of the Department of Health as part of its role …
Accepted
11 — Raise awareness of incident reporting and duty of candour
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
IHRD-7 — Monitoring Candour Compliance
Recommendation: Trusts should monitor compliance and take disciplinary action against breach.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-6 — Support for Candour Compliance
Recommendation: Support and protection should be given to those who properly fulfil their duty of candour.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-5 — Employment Contracts and Duty of Candour
Recommendation: Trusts should review their contracts of employment, policies and guidance to ensure that, where relevant, they include and are consistent with the duty of candour.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-4 — Trust Awareness of Duty of Candour
Recommendation: Trusts should ensure that all healthcare professionals are made fully aware of the importance, meaning and implications of the duty of candour and its critical role in the provision of healthcare.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-1 — Statutory Duty of Candour
Recommendation: A statutory duty of candour should now be enacted in Northern Ireland so that: (i) Every healthcare organisation and everyone working for them must be open and honest in all their dealings with patients and the public. (ii) Where death …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IBI-5c — Ministerial Duty of Candour
Recommendation: The Government should consider the extent to which Ministers should be subject to a duty beyond their current duty to Parliament under the Ministerial Code.
Gov response: These recommendations are accepted in principle and the Prime Minister has committed to bringing forward legislation on a duty of candour for public servants. The actions of Civil Servants and Ministers uncovered within the report …
Accepted in part
IBI-5b — Monitoring Non-Statutory Duties
Recommendation: If, on review, the Government considers that it is sufficient to rely on the current non-statutory duties in the Civil Service Code, it should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness …
Gov response: These recommendations are accepted in principle and the Prime Minister has committed to bringing forward legislation on a duty of candour for public servants. The actions of Civil Servants and Ministers uncovered within the report …
Accepted in part
IBI-5a — Civil Service Statutory Duty of Candour
Recommendation: The Government should reconsider whether, in the light of the facts revealed by this Inquiry, it is sufficient to continue to rely on the current non-statutory duties in the Civil Service and Ministerial Codes, coupled with those legal duties which …
Gov response: These recommendations are accepted in principle and the Prime Minister has committed to bringing forward legislation on a duty of candour for public servants. The actions of Civil Servants and Ministers uncovered within the report …
Accepted in part
BRIS-117 — Require contractual stipulation for confidential, non-disciplinary reporting of sentinel events.
Recommendation: There should be a stipulation in every healthcare professional’s contract that sentinel events must be reported, that reporting can be confidential, and that reporting within a specified time period will not attract disciplinary action.
Unknown
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
BRIS-24 — Treat patient consent as an ongoing process, not a single signature event
Recommendation: The process of informing the patient, and obtaining consent to a course of treatment, should be regarded as a process and not a one-off event consisting of obtaining a patient’s signature on a form.
Unknown
14 — Board apologies
Recommendation: We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Gov response: Accept Healthcare organisations have a statutory duty of candour, which sets out specific requirements providers must follow when things go wrong with care and treatment, including providing truthful information and an apology. This duty is …
Accepted
IHRD-42 — Sharing New Investigation Information
Recommendation: In the event of new information emerging after finalisation of an investigation report or there being a change in conclusion, then the same should be shared promptly with families.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F180 — Candour about incidents
Recommendation: Guidance and policies should be reviewed to ensure that they will lead to compliance with Being Open, the guidance published by the National Patient Safety Agency.
Gov response: Accepted. As stated in recommendation 174, the intention is introduce an explicit duty of candour on providers as a Care Quality Commission registration requirement. The Department of Health will publish shortly draft regulations on a …
Accepted
24 — Involve patients and relatives in incident investigation
Recommendation: We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking …
Gov response: 37. We accept this recommendation. A duty of candour has been introduced. 38. A lack of openness and honesty at Morecambe Bay was a fundamental cause of both the distress of the families, and of …
Accepted
1 — Admit problems and apologise to affected families
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
IHRD-3 — Guidance on Statutory Duty of Candour
Recommendation: Unequivocal guidance should be issued by the Department to all Trusts and their legal advisors detailing what is expected of Trusts in order to meet the statutory duty.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-2 — Criminal Liability for Candour Breach
Recommendation: Criminal liability should attach to breach of this duty and criminal liability should attach to obstruction of another in the performance of this duty.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IBI-4b — Organisational Culture Change
Recommendation: Cultural Change: That a culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns about patient safety be addressed both by taking the steps set out in (a) above, and also by making leaders accountable …
Gov response: This recommendation is accepted in principle by the UK Government, the Welsh Government, the Scottish Government and the Northern Ireland Executive.
Accepted in part
IBI-4a(v) — Leadership Accountability for Safety
Recommendation: Statutory duty of candour: Individuals in leadership positions should be required by the terms of their appointment and by secondary legislation to record, consider and respond to any concern about the healthcare being provided, or the way it is being …
Gov response: 4a) v. Advancing patient safety and reducing harm in the NHS is a priority for this Government. We acknowledge the importance of recording and responding to patient safety incidents and the underpinning principle of this …
Accepted in part
IBI-4a(iv) — Individual Duty of Candour for Leaders
Recommendation: Statutory duty of candour: The statutory duties of candour in England, Scotland, Wales (and Northern Ireland, when introduced) should be extended to cover those individuals in leadership positions in the National Health Service, in particular in executive positions and board …
Gov response: 4a) iv. The Government recognises the importance of strong and accountable leadership in fostering an open and compassionate culture in the NHS. That is why we have committed to implementing professional standards for and regulating …
Accepted in part
IBI-4a(iii) — Duty of Candour - England Review
Recommendation: Duty of candour: The review of the duty of candour currently under way in England should be completed as soon as practicable.
Gov response: The Government is clear that the statutory (organisational) duty needs to act as a catalyst for health and social care providers to improve openness and commit to a learning culture. The Government is supportive of …
Accepted
IBI-4a(ii) — Duty of Candour - Scotland and Wales Review
Recommendation: Duty of candour: The operation of the duties of candour in healthcare in Scotland and in Wales should be reviewed, as it is being in England, to assess how effective its operation has been in practice. Since the duty was …
Gov response: The organisational duty of candour provisions of the Health (Tobacco, Nicotine etc. and Care) (Scotland) Act 2016 and the Duty of Candour Procedure (Scotland) Regulations 2018 set out the procedure that organisations providing health services, …
Accepted
IBI-4a(i) — Duty of Candour - Northern Ireland
Recommendation: Duty of candour: A statutory duty of candour in healthcare should be introduced in Northern Ireland.
Gov response: As part of the Health and Social Care Three Year plan, Minister Mike Nesbitt committed to advance proposals for an organisational duty of candour, in the first instance, as well as considering proposals for an …
Accepted
DM-17 — Statutory duty of candour for law enforcement
Recommendation: The Panel recommends the creation of a statutory duty of candour, to be owed by all law enforcement agencies to those whom they serve, subject to protection of national security and relevant data protection legislation.
Gov response: 2.3.2. The Panel agreed with other independent inquiries, such as Bishop James Jones’ report on the experiences of the Hillsborough families, about the need for a duty of candour for public services, including the police. …
Response Unclear
BRIS-115 — Discipline NHS staff who cover up or fail to report sentinel events
Recommendation: Members of staff in the NHS who cover up or do not report a sentinel event may be subject to disciplinary action by their employer or by their professional body.
Unknown
BRIS-114 — Grant immunity for NHS staff reporting sentinel events within 48 hours
Recommendation: Members of staff in the NHS should receive immunity from disciplinary action by the employer or by a professional body if they report a sentinel event to the trust or to the national database within 48 hours, except where they …
Unknown
BRIS-113 — Make reporting of sentinel events easy using all communication means
Recommendation: The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Unknown
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
BRIS-25 — Extend consent process to all clinical procedures involving touching, focusing on communication
Recommendation: The process of consent should apply not only to surgical procedures but to all clinical procedures and examinations which involve any form of touching. This must not mean more forms: it means more communication.
Unknown
BRIS-23 — Endorse and implement DoH consent guide across all NHS healthcare professional practice
Recommendation: We note and endorse the recent statement on consent produced by the DoH: ‘Reference guide to consent for examination or treatment’, 2001. It should inform the practice of all healthcare professionals in the NHS and be introduced into practice in …
Unknown
R69 — Explanation to relatives on CDI death
Recommendation: Health Boards should ensure that if a patient dies with CDI either as a cause of death or as a condition contributing to the death, relatives are provided with a clear explanation of the role played by CDI in the …
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
CR17 — Protocol for duty to assist referrals
Recommendation: HM Coastguard and the Maritime and Coastguard Agency should establish a protocol for referrals by HM Coastguard to the Maritime and Coastguard Agency's regulatory compliance investigations team, identifying the threshold for making a referral on a potential breach by a …
Gov response: HMCG accepts the importance of a protocol for making referrals to the Regulatory Compliance and Investigations team (RCIT) and revised its SOPs in October 2023 to enshrine this practice. This update reminded all staff of …
Accepted
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
Prevention of Future Deaths reports(39)
James Withers
Concerns: The coroner identified delays in cardiologist review, missing medical notes, and poor communication among staff and with the family. Concerns included the Do Not Attempt Resuscitation (DNAR) process lacking family discussion, and a doctor incorrectly assuming the status.
Overdue
Hilda Haughton
Concerns: Unraised cot sides led to a patient falling from bed, and hospital staff showed a lack of candour about the incident. Concerns were also raised about the increased time taken for fire doors to close at the hospital.
Response (Department of Health): • The Department of Health issued an Estates and Facilities Safety Alert (EFA/2015/006) to the NHS in England on 3rd December 2015. • The alert was designed to raise awareness … (AI summary)
Response (Hilda Haughton): • The Trust reviewed its policies and procedures regarding the statutory duty of candour. • The Trust conducted workshops for over 75 staff on investigations, Root Cause Analysis, communication, and … (AI summary)
Responded
Frank Mellers
Concerns: The coroner noted the patient's DNAR status was fixed without family discussion, contrary to good practice. There was poor communication between nursing and medical staff, leading to a resuscitation attempt despite a DNAR order.
Response (Frank Mellers): • The organisation reiterated the importance of daily ward rounds and developed a Ward Board indicator to highlight DNAR status to all staff. • The DNAR policy was reviewed to … (AI summary)
Overdue
Jack Susianta
Concerns: The consultant psychiatrist did not communicate clear clinical expectations to Jack's family before discharge, including what recurrence of psychotic symptoms would signify and when to seek urgent professional help. This left the family unaware of when immediate re-hospitalisation might be necessary.
Overdue
Sally Froggatt
Concerns: The coroner raised concerns regarding inadequate staff training and a failure to comply with the duty of Candour. It was also noted that corporate pharmacy guidelines contradicted NICE guidance and nursing staff did not alert consultants to known risk factors.
Overdue
Geraldine Butterfield
Concerns: The coroner noted insufficient staff knowledge regarding the BUPA choking policy and an inadequate understanding of when life-sustaining treatment should be provided to individuals with a DNAR order.
Overdue
Sam Crick
Concerns: The coroner noted that neuroradiological reviews missed obvious signs of rising intracranial pressure on CT scans, and a critical report was not available for a key neurosurgeon consultation. There was also a lack of a Serious Incident Report for a preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): • A Significant Incident (SI) notification was completed, and an SI was declared on 31 August 2017, with an investigation ongoing. • The Trust developed a 'Learning Deaths' policy and … (AI summary)
Response (CQC): • The CQC contacted Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) to request confirmation and evidence of actions taken and planned in response to the PFD report. • … (AI summary)
Response (NHS England): • NHS England stated it would work with the Society of British Neurological Surgeons and the Royal College of Emergency Medicine to produce and distribute national guidance on the use … (AI summary)
Responded
David Lindsey
Concerns: The coroner noted family contentions regarding the trust's adherence to NICE guidelines and its own policies for cancer screening, referrals, diagnosis, and treatment.
Overdue
Francesca Whyatt
Concerns: The coroner identified a lack of risk assessment for the East Wing ward's multi-floor layout and insufficient formal guidance on observation competency for agency staff. Further concerns included a lack of clear policy for classifying and investigating ligature incidents as Serious Untoward Incidents.
Response (Priory Hospital): • The hospital confirmed that environmental risk assessments, including ligature and safety audits, are conducted twice yearly and refreshed annually. • A new requirement has been added to Policy H43, … (AI summary)
Overdue
Patricia Forshaw
Concerns: The coroner identified ambiguous discharge information, an unrecorded telephone call giving medical advice, and insufficient documentation or escalation of nurse observations. There was also no formal policy for routine observations in wound review clinics, even with indications of infection.
Response (Wrightington Wigan and Leigh NHS Trust): • A memo was sent to all Emergency Care staff instructing them to direct callers seeking advice to their GP, NHS 111, or Accident & Emergency, and not to provide … (AI summary)
Responded
Helen Cannon
Concerns: Emergency responders did not seek medical assistance for a patient with a pelvic fracture that led to internal haemorrhage, contrary to good practice. A subsequent investigation was flawed, failing to address inaccuracies in a risk assessment checklist and a responder's understanding of their signature.
Overdue
Rose Ball
Concerns: The coroner identified inaccurate record-keeping by a doctor, noting telephone consultations were misrepresented as in-person and a non-existent abdominal examination was recorded. A pattern of telephone diagnoses at the practice was also raised, leading to a referral to the GMC.
Overdue
Emmett Gillah
Concerns: The coroner noted insufficient detail in discharge letters to GPs and KMPT's failure to adhere to its policy for post-discharge patient contact. Concerns were also raised about inadequate communication with patient families regarding discharge decisions and staff unawareness of relevant policies.
Overdue
Elisa Fuller
Concerns: The report noted a lack of appropriate support and systems to encourage junior midwives and doctors to escalate concerns, and insufficient understanding of the need to retain placentas post-delivery.
Response (Gloucestershire Hospitals NHS Trust): • The Trust confirmed it provides mandatory update days, rotation day programmes, and multi-professional training for staff, which include sessions on escalation and communication. • The Trust revised its policy … (AI summary)
Responded
David Smith
Concerns: The donor's CMV status was not communicated to the deceased for informed consent, nor was this critical information effectively shared with the renal transplant team, indicating a gap in their communication process.
Response (Manchester University NHS Trust): • The consent process for transplantation was strengthened to ensure recipients are informed about CMV infection and its effects. • An independent check process for donor and recipient documentation, including … (AI summary)
Responded
Emma Langley
Concerns: The paramedic did not consider meningitis or use the Sepsis Tool, which would have indicated the need for hospital conveyance. Additionally, communication with the family about the necessity of hospital admission was insufficient, leading to a misunderstanding.
Response (West Midlands Ambulance Service NHS Trust): • The Trust is changing its electronic patient report software to include a clear statement for patients/families to read before signing, acknowledging refusal of treatment/transport/referral against medical advice and understanding … (AI summary)
Responded
Andrew Wells
Concerns: The coroner noted deficiencies in the Trust's Root Cause Analysis process, particularly the lack of psychiatric expertise and scrutiny, and raised concerns about clinicians not appropriately applying the Mental Health Act regarding 'de-facto' detention.
Overdue
Ifeoma Onwuka
Concerns: The coroner identified concerns regarding an on-call consultant's apparent lack of confidence to perform emergency hysterectomy without a second consultant, insufficient professional curiosity about the cause of DIC, and a lack of leadership in patient care. This may place pregnant women requiring emergency surgery at risk.
Overdue
Agnes Sansom
Concerns: Patient record systems do not ensure timely communication of urgent information to relevant staff, and vulnerable patients are obliged to share walking aids on hospital wards.
Response (County Durham and Darlington NHS): • Physiotherapists now record changes in patient mobility or required interventions in the Nervecentre mobility gallery. • A buffer stock of walking aids has been implemented in hospitals to ensure … (AI summary)
Responded
John Long
Concerns: The coroner noted the design of bed rails could allow patients to fall easily. Concerns also include the definition, administration, staff breaks, and training communication of 1:1 care in hospital settings.
Overdue
Peter Cole
Concerns: The coroner identified inadequate monitoring and supervision of repeat medication, leading to patients receiving dangerous quantities and widespread waste of healthcare resources.
Response (NHS England): • NHS England stated that Primary Care Networks are able to recruit clinical pharmacists to conduct structured medication reviews for patients with ongoing health problems. • NHS England is undertaking … (AI summary)
Responded
Susan Roberts
Concerns: The coroner identified insufficient timely and effective handover between surgical specialties due to an absence of formal protocol. There were also concerns about the engagement of Plastic Surgeons during a theatre incident and a subsequent investigation.
Response (Bradford Teaching Hospitals NHS Foundation Trust): • A protocol for cases of Necrotising Fasciitis has been issued, stipulating which specialties need to be contacted and at what point in treatment. • The Trust is revising its … (AI summary)
Responded
William Doleman, Anita Burkey, Peter Sellars and Carol Cole
Concerns: The coroner identified gaps in the patient pathway for ERCP procedures, including insufficient identification of patient factors, lack of robust systems for recording procedure vetting, and non-personalised consent processes, compounded by a lack of professional accountability.
Response (City Hospital Campus): • The Surgical Division’s Governance Committee would oversee the delivery of actions. • The Quality and Safety Oversight Group would receive reports on progress. • The Quality Assurance Committee, a … (AI summary)
Responded
Robert Murray
Concerns: The coroner noted a lack of understanding among care home staff and call operators regarding when a DNACPR order should not be applied, indicating a need for further training and clarification.
Response (NMC): • The NMC introduced new 'Future Nurse' standards of proficiency in 2018, which include specific requirements for registered nurses regarding end-of-life care and DNACPR decisions. • Its Code of conduct … (AI summary)
Response (Adult Social Care): • Avalon Nursing Home updated advice related to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) and RESPECT forms and included it in care plans. • Staff, senior care staff, and managers … (AI summary)
Responded
Marnie Hill
Concerns: The coroner identifies a risk of future deaths due to the lack of regulation for counsellors in England and Wales, which includes no requirements for training, record-keeping, or reporting self-harm risks.
Response (South Western Ambulance Service NHS Foundation Trust): • The Trust contacted Private Ambulance Providers (PAPs) to remind them of the Appropriate Care Pathway Policy for GP referrals and the requirement for direct referrals or verbal information sharing. … (AI summary)
Response (NHS Dorset ICB): • Discussions are ongoing between Dorset HealthCare, SWASFT, and the police regarding operational processes for supporting individuals in crisis, including exploring a trusted assessor model. • The ICB indicated it … (AI summary)
Response (Department of Health and Social Care): • The Department will publish its response to the public consultation on the criteria for determining when statutory regulation of a healthcare profession is appropriate. (AI summary)
Responded
Samantha Shillito
Concerns: The coroner identified insufficient specialist consultant review for a patient with a high NEWS score, and noted concerns regarding unquantified risks and inadequate informed consent for the ascitic tap procedure.
Response (Mid Yorkshire Teaching NHS Trust): • The Trust introduced the 24/7 Deteriorating Adult Response Team (DART) and launched the Call 4 Concern patient safety initiative. • The Trust will review its patient safety leaflets for … (AI summary)
Response (The Royal College of Radiologists): • The Royal College of Radiologists confirmed it had put additional measures in place to refine its process for responding to important correspondence. (AI summary)
Responded
Sarah Chappell
Concerns: Concerns were raised about delays in hospital transfer, confusion over clinical leadership, and inadequate management of a nasogastric tube, leading to a fatal aspiration. The report also notes insufficient pain relief and a misunderstanding of the patient's acute needs.
Response (University College London Hospitals NHS Foundation Trust): • The Trust has strengthened its governance structures, with the chief nurse now chairing the safeguarding adults committee and the learning disability steering group. • The Trust will update its … (AI summary)
Responded
Benjamin Leonard
Concerns: The coroner noted a lack of candour within The Scouts Association and the absence of independent regulatory oversight for its safety systems and activity permits. There was also concern about the failure to conduct a timely internal investigation report following the child's death.
Response (Charity Commission for England and Wales): • The Charity Commission has maintained an open regulatory case concerning The Scout Association (TSA) since August 2018. • The Commission met with senior personnel from TSA on 19 March … (AI summary)
Response (Minister for Education Wales): • The Minister for Education Wales stated that the UK Government was best placed to respond to the recommendation for a Public Inquiry into the Scout Association. • The Minister … (AI summary)
Response (Childrens Commissioner for Wales): • The Commissioner will continue to seek updates from the Scouts Association regarding their actions to prevent future deaths or serious injuries. • The Commissioner will share a copy of … (AI summary)
Response (Childrens Commissioner): • The Children's Commissioner's team will request updates from the Scouts Association regarding their learning exercise. • The initial request for updates is scheduled for 30th April 2024. (AI summary)
Response (Department for Education): • The Department for Education stated it would launch a Call for Evidence in summer to explore options for strengthening safeguarding and oversight in the Out-of-School settings sector. • The … (AI summary)
Response (Health and Safety Executive): • The Health and Safety Executive has begun an investigation into Ben Leonard's death. • The Health and Safety Executive will undertake a review to identify how the error in … (AI summary)
Response (Scout Association): • A Fatal Accident Investigation into Ben's death was commissioned within 48 hours of the inquest, with the initial report due by June 2024. • The Board agreed to develop … (AI summary)
Responded
Olayemi Kehinde
Concerns: The coroner raises concerns about the ability of staff supervising S.17 leave to identify serious incidents requiring intervention, and the Trust's capacity to identify matters needing full governance investigation.
Response (NELFT): • New guidance for staff supervising Section 17 leave has been prepared, detailing processes and actions for identifying serious incidents. • This guidance will be implemented in June 2024, communicated … (AI summary)
Responded
Sophie Dean
Concerns: The coroner identified gaps in medical records, including incomplete entries by junior doctors after ward rounds. Concerns were also raised about the adequacy of discussions regarding treatment options and consent with the patient's family prior to surgery.
Response (UCLH): • UCLH stated that subspecialty teams will establish minimum requirements for ward round notes, with divisions auditing compliance within 12 months. • The consent policy has been amended to require … (AI summary)
Responded
Janet Seddon
Concerns: The coroner identified a delayed diagnosis of abdominal pathology from a CT scan that contributed to death. Concerns include significant delays by the Trust in investigating the reporting error, assessing harm, disclosing it to the family and coroner, and evidencing learning.
Response (York Scarborough Teaching Hospitals NHS Foundation Trust): • The Trust implemented the new Patient Safety Incident Response Framework (PSIRF) in December 2023, establishing revised systems for incident management and learning. • The Incident Management Policy and Procedures … (AI summary)
Responded
Denise Johnson
Concerns: The coroner noted insufficient timely notification and formal review for ERCP procedure complications. There were also gaps in regular, comprehensible communication with next of kin about management plans, and a lack of clarity regarding named Surgical Consultant cover during unexpected leave.
Response (East Suffolk and North Essex Foundation Trust): • The Trust's endoscopy unit will start 3-monthly Multi-Disciplinary Team meetings to discuss all ERCP cases and complications. • A new visitor's charter will be introduced in late Spring 2025, … (AI summary)
Responded
Cynthia Gilbert
Concerns: A patient at very high risk of pressure ulcer development was not repositioned according to her care plan for many hours on multiple days, despite repeated advice. The Trust's post-death investigation did not provide a satisfactory explanation for this non-adherence.
Response (Somerset NHS Foundation Trust): • The Trust commenced a Quality Improvement project in September 2024 to improve understanding and application of Intentional Rounding. • A mandatory eLearning module for Pressure Ulcer Prevention was introduced, … (AI summary)
Responded
Darren Turner
Concerns: The coroner noted failures in updating and documenting care plans and risk assessments, along with inadequate electronic record-keeping. Additional concerns included the non-allocation of a care coordinator and insufficient communication with the family, impacting discharge planning.
Response (Essex Partnership University NHS Foundation Trust): • The Trust has implemented weekly care plan reviews, introduced Practice Nurse Educators, and initiated a Record Keeping Safety Improvement Programme. • The Trust has established family ambassadors, is rolling … (AI summary)
Responded
Mabel Williams
Concerns: The Trust's patient information leaflets on 'Birth after caesarean' lacked a full explanation of uterine rupture, impacting informed consent for VBAC. There are concerns that the Trust may not be implementing changes following serious clinical incidents within a reasonable timeframe.
Response (Great Western Hospitals NHS Foundation Trust): • The Trust revised its 'Birth After Previous Caesarean' patient information leaflet to include a clear explanation of uterine rupture risks, and this updated leaflet is now available to staff … (AI summary)
Responded
William King
Concerns: Inadequate documentation of consent discussions and insufficient explanation of risks regarding an NG tube were identified. The coroner noted non-compliance with existing policies and an absence of clear professional responsibility for ensuring crucial care explanations.
Response (Royal College of Surgeons of England): • The Royal College of Surgeons of England stated it is updating its consent guidance and will consult with the Royal College of Anaesthetists for coordinated advice. • The College … (AI summary)
Response (Association of Anaesthetists and Royal College of Anaesthetists): • The organisations stated they would publish a Good Practice guide on rapid sequence induction, which addresses considerations for nasogastric tube use and patient understanding of risks. • They confirmed … (AI summary)
Response (Milton Keynes University Hospitals NHS Foundation Trust): • The Trust reviewed a Regulation 28 Report issued by HM Senior Coroner for Manchester North. • The Trust is designing a new electronic form within its patient record system … (AI summary)
Responded
Amber Walker
Concerns: The coroner identifies insufficient discussion of SUDEP risks with epilepsy patients, citing doctors' reluctance, a presumption of prior conversations, and a lack of universal tools. SUDEP also being absent from medical training contributes to gaps in patient awareness.
Response (Department of Health and Social Care): • The Department noted that National Institute for Health and Care Excellence (NICE) guidance outlines best practice for discussing SUDEP risk with epilepsy patients and their families. • NHS England's … (AI summary)
Responded
Lee Eustace
Concerns: The Trust did not comply with its statutory Duty of Candour, failed to properly investigate an incident internally, and did not adhere to disclosure duties to the Coroner, leading to delayed provision of critical information.
Response (University Hospitals Plymouth NHS Trust): • The jejunostomy feeding protocol was revised in September 2022 to include a daily checklist with explicit instructions for abdominal pain and clinical warning signs. • The pathway for all … (AI summary)
Responded
Graham Oxley
Concerns: The coroner raises concerns about the reliable operation of systems for early recognition and escalation of serious immunotherapy toxicity, noting that urgent oncology advice may be delayed and immunotherapy alert cards do not trigger a priority pathway.
Response (Sheffield Teaching Hospital NHS Foundation Trust): • The Trust redesigned patient contact methods for the Weston Park Cancer Centre, introducing a three-option menu for the triage line to redirect non-urgent calls. • Call-handling escalation arrangements were … (AI summary)
Responded
Select committee recommendations(19)
#8 —
Recommendation: The Government should consider introducing a statutory duty of candour and extend it to all public authorities, as called for in the Hillsborough Law. (Paragraph 71) Human rights and the proposal for a “Hillsborough Law” 29 Legal Representation and the …
Response attribution not verified
#7 —
Recommendation: A variety of existing laws and guidance require openness from public authorities and cooperation with official investigations and inquiries. This patchwork demonstrates longstanding recognition that openness and transparency from public authorities is of real importance. Yet from the evidence we …
Response attribution not verified
#6 —
Recommendation: A general statutory duty of candour would help to ensure that the priority for public bodies is to establish what has gone wrong and needs to be changed in order to prevent future deaths, rather than protecting individuals and institutions …
Response attribution not verified
#5 —
Recommendation: While taking a step in the right direction, the current provisions of the Criminal Justice Bill do not offer the same opportunity for change as would a general statutory duty of candour. By focusing on the police alone and appearing …
Response attribution not verified
#4 —
Recommendation: Given the importance of transparency, including criminal sanctions in any statutory duty of candour appears justified, but the right not to self-incriminate, protected at common law and under Article 6 ECHR, must also be respected.
Response attribution not verified
#3 —
Recommendation: Introducing criminal sanctions for breach of a duty of candour may increase the prospect of the duty being taken seriously, offering greater external mechanisms to pursue public institutions that fail to comply. However, including criminal offences on the statute book …
Response attribution not verified
#1 —
Recommendation: We welcome the Government’s signing of the Hillsborough Charter and its commitment to honesty and transparency in the public sector, features that can only benefit the protection of human rights. (Paragraph 17) A Duty of Candour
Response attribution not verified
#22 —
Recommendation: The government should publicly commit to ensuring that the Duty of Candour under the Public Office (Accountability) Bill applies in the same way to legacy inquests conducted by coroners as to inquisitorial proceedings conducted by the Legacy Commission. (Recommendation, Paragraph …
Response status not verified
#21 —
Recommendation: It is unacceptable that the government has not given an unambiguous commitment that the Duty of Candour will apply to any revived inquest conducted by a coroner in the same way as it would apply to any revived 94 inquest …
Response status not verified
#2 —
Recommendation: “Institutional defensiveness” appears to remain a problem for public authorities, particularly when they are involved in public inquiries and inquests. This hinders efforts to establish the truth when things go wrong and stands in the way of fulfilling the State’s …
Response attribution not verified
#10 —
Recommendation: The failure of health and social care bodies to fulfil their duty of candour to bereaved people during coroners’ investigations and inquests is disappointing. The Ministry of Justice should amend the Coroners’ rules to make it patently clear that the …
Response attribution not verified
#17 —
Recommendation: It is clear to us that in its current form the clinical negligence process is failing to meet its objectives for both families and the healthcare system. Too often families are not provided with the appropriate, timely and compassionate support …
Response attribution not verified
#37 — Formally consider introducing a professional duty of candour to increase police transparency.
Recommendation: We recommend that the NPCC, College of Policing, Home Office and Association of Police and Crime Commissioners formally consider whether a professional “duty of candour” might drive greater transparency in policing. We consider that, while this would not be enough …
Response attribution not verified
#22 —
Recommendation: Finally, given their recognition of the role the professional regulators have in ending the blame culture, we recommend that the General Medical Council and the Nursing and Midwifery Council review what changes are required to their remits or working practices …
Response attribution not verified
#11 —
Recommendation: We believe that HSIB’s ability to take a broad and independent view of the services and factors contributing to maternity incidents is a valuable step in the right direction to learning from maternity incidents. It is essential that an independent, …
Response attribution not verified
#10 —
Recommendation: Involving families in a compassionate manner is a crucial part of the investigation process. Too often, maternity investigations have failed to do this in a meaningful way. Families must be confident that their voices are heard and that lessons have …
Response attribution not verified
#12 —
Recommendation: Clinicians of all disciplines should also receive training before they are qualified in how they should respond to the sorts of error that these investigations may uncover. This would include help for clinicians on accepting a degree of fallibility. Being …
Response attribution not verified
#11 — Mandate Ofgem and energy companies to adopt a proactive culture improving consumer standards.
Recommendation: Ofgem and energy companies need to adopt a more proactive culture in improving industry consumer standards. Energy companies should not wait to be enforced to certain standards by Ofgem but should be innovating to improve customer satisfaction and attract more …
Response attribution not verified
#10 — Ofgem and energy companies failed to proactively improve consumer standards for winter.
Recommendation: While we welcome the forthcoming set of consumer standards, we are disappointed that Ofgem did not anticipate the need for significant improvements ahead of this winter. Introducing them from December 2023 will likely be too late to see significant 12 …
Response attribution not verified
NCEPOD recommendations(1)
CQC inspection actions(33)
Nottingham City Hospital
The trust must ensure that it complies with its statutory responsibilities for duty of candour.
Must Do
University Hospital of Hartlepool
The trust should consider auditing its application of Duty of Candour legislation regularly to ensure compliance.
Should Do
University Hospital of Hartlepool
The service must ensure that the Duty of Candour regulation is met in full for all notifiable safety incidents.
Must Do
University Hospital of Hartlepool
The trust must ensure that it complies with Duty of Candour regulations.
Must Do
Royal Victoria Infirmary
The service must ensure that Duty of Candour is given in full to patients when incidents occur.
Must Do
Royal Victoria Infirmary
The service must ensure that Duty of Candour is given in full to patients when incidents occur.
Must Do
Queen's Medical Centre
The trust must ensure that it complies with its statutory responsibilities for duty of candour.
Must Do
Pilgrim Hospital
The trust should ensure the requirements of duty of candour are met.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that staff have received training and are aware of the duty of candour regulations.
Should Do
Leighton Hospital
The service must ensure that incidents are graded in accordance with the Health and Social Care Act Regulation 20 Duty of Candour level of harm criteria to make sure people receive follow up care following an incident.
Must Do
Fleetwood Hospital
The trust must ensure that the duty of candour is applied in line with legislation.
Must Do
St Benedict's Hospice
The trust should ensure Duty of Candour requirements are clearly documented and undertaken in a timely way.
Should Do
Musgrove Park Hospital
The service must ensure they apply and demonstrate compliance with Duty of Candour requirements.
Must Do
James Paget Hospital
The service should ensure that duty of candour is carried out for all eligible incidents.
Should Do
Family Nurse Partnership & Health Visiting
The service should ensure that staff always offer an apology to people when things go wrong and record this when they have done so.
Should Do
Durham Diagnostics and Treatment Centre
The trust should ensure Duty of Candour requirements are clearly documented and undertaken in a timely way.
Should Do
Clifton Hospital
The trust must ensure that the duty of candour is applied in line with legislation.
Must Do
Verve Health
The service must ensure staff are applying the duty of candour when things go wrong.
Must Do
Edwina Place
The provider should seek advice and guidance from a reputable source about Regulation 20: Duty of Candour to ensure requirements are met at all times, including clear record keeping.
Should Do
Universal Care - Beaconsfield
We recommend the provider seek guidance from a reputable source to ensure the duty of candour requirements are fully understood by all staff.
Should Do
My Homecare Peterborough
The provider had failed to notify the Care Quality Commission about incidents they are required to.
Must Do
Kingfishers Nursing Home
The service implements a system to meet the requirements of the duty of candour process.
Should Do
Gallaudet Home
We recommend that the manager ensures they update their knowledge on the duty of candour from a reliable source and take action to update their practice accordingly
Should Do
Universal Care - Beaconsfield
the provider sought guidance from a reputable source to ensure the duty of candour requirements were fully understood by all staff.
Should Do
Nicholas House
The provider must ensure that the registered provider acts in an open and transparent way with relevant persons when notifiable events occur.
Must Do
Kingsleigh Residential
The provider had failed to ensure correct information was given to people when something had gone wrong.
Must Do
Shining Star Home Care Limited
There were gaps in the providers knowledge of when notifications were required to be submitted. We found that allegations of abuse notifications had not been submitted, as the provider's knowledge of when these types of notification should be sent was …
Should Do
Shining Star Home Care Limited
Improvements were needed in the providers systems to ensure the CQC were notified of events around allegations of abuse.
Should Do
Church Road
The provider ensures all staff and managers are familiar with the requirements of the regulations regarding duty of candour so they act in accordance with these.
Should Do
Cygnet Bury Hudson
The provider should ensure that all staff know what the specific roles are in relation to independent mental health advocates and independent mental capacity advocates and have a good understanding of the duty of candour.
Should Do
Medrescue Headquarters
TheservicemustensurethatitfollowscorrectprocesswhensubmittingstatutorynotificationstotheCQCunder theirresponsibilityasaregisteredprovider.
Must Do
The Elms
The registered manager must notify CQC of all reportable incidents.
Must Do
The Olde Coach House
The provider seeks advice and reviews their policy and practice relating to notifiable events to the CQC.
Should Do
ICIBI immigration recommendations(3)
An inspection of asylum casework (June – October 2023)
Introduce, as a matter of urgency, a published service standard
An inspection of the immigration system as it relates to the social …
Work in partnership with the responsible government departments and agencies to agree a concise ‘migrant’s guide to UK employment rights’, which can be proactively shared with migrants at the earliest …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to initial age assessments and decisions: Publish guidance on the ‘age admit’ process, setting out the steps required to ensure that anyone asked to sign a ‘Statement of …
PPO death in custody recommendations(1)
IMB individual recommendations(4)
Lowdham Grange (2024)
What action is being taken to address HM Coroner’s stated concerns, including: a failure to investigate whether anything could have been done to prevent the deaths; failure to seek any lessons from the deaths; failure to implement any findings of the Prisons and Probation Ombudsman (PPO); and the failure to inform staff of policies and procedures relating to the deaths, …
Governor / Director
Noted
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Governor / Director
Noted
Tinsley House IRC (2020)
to ensure that HOIE Rule 35 notification responses are tailored to the individuals to whom they relate, and that those responses are genuinely meaningful.
Home Office
Derwentside IRC (2023)
To ensure that all residents are made aware of rule 35 on arrival to enable access to a medical practitioner and provision of reports to case-owners as soon as possible after arrival in detention.
NHS / Healthcare Provider
Health investigations(94)
Independent investigation: Gary Miller, Plymouth (2016) — Rec Recommendation 8
Livewell Southwest should ensure that all staff are aware of and adhere to the Duty of Candour Regulation 20, particularly in relation to the provision of a written apology and a description of what further enquiries the provider believes are appropriate.
south_west
Independent investigation: Alan Creasey, Lancing (2017) — Rec 1
The Trust needs to ensure appropriate application of Duty of Candour in cases of homicide.
south_east
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
All authorities mandated to set up inquiries under NHS Executive Guidance HSG(94)27 of 10 May 1994 should actively consider including in their Terms of Reference directions that families of victims should be given the opportunity to be present at any Inquiry into homicide, whether the Inquiry is held in public …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Employers, their legal advisers and insurers should find ways of helping their staff make direct personal contact with bereaved families, unless the families do not wish for this.
east_of_england
Independent investigation: John Stevens, Woking (2001) — Rec 20
We recommend that the North West Surrey Mental Health Partnership Trust should make contact with families who are the victims of serious incidents and implement a staff training programme which takes account of the sensitive nature of support required seeking guidance from and including the various voluntary agencies such as …
south_east
Independent investigation: Tracy Anstice, Flitwick (2011) — Rec 7
SEPT should have a clear process in place to ensure that those affected by serious incidents are supported and involved in the trust internal investigation to meet the requirements of the statutory duty of candour.
east_of_england
Independent investigation: Terry Wilson, Wewlyn Garden City (2006) — Rec 2
The Trust should review the ‘Learning from Adverse Events’ policy to ensure that its application has the intended effect of applying the ‘Being Open’ principles in relation to victims and relatives.
london
Independent investigation: Steven Janczuk, Arlesey, Beds (2006) — Rec 8
The Trust should communicate with the victim’s and service-user’s families immediately following an incident to offer condolences, explain the Trust’s investigative processes and where appropriate offer an apology and provide support options. The Trust should consider, where contact with the family has not been established, that action is taken to …
east_of_england
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 1
It is the panel’s clear view, and our first recommendation, that the Board should publish this report, and that it should provide copies, in advance, to the two families involved. In support of this recommendation we have not used the names of staff involved. The panel acknowledges that the Board, …
northern_ireland
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 13
The Trust must ensure there is clarity in the PSIRF policy about involving families in the investigation of incidents and this involvement should be supervised and quality assured. Communication with families must be timely and unambiguous, in accordance with the principles of being open. This is set out in guidance …
south_west
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 8
The Trust must ensure that Hospital 2 and EIT staff seek to involve family members (or other relevant third parties), and that family evidence/collateral information is used appropriately, particularly when the patient is unable or unwilling to engage in meaningful interactions themselves.
south_west
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 7
The Trust must ensure that the MHA Office communicates with the NR when decisions are made about changes to the patient’s detention.
south_west
Independent investigation: Ryan Merna, Poole — Rec 10
The Trust must ensure that all communications executing their Duty of Candour responsibilities (including when acting in the spirit of Regulation 20) fulfils all of the requirements of the Regulation.
south_west
Independent investigation: Rodney Wells, Nottingham (2006) — Rec R5
The trust should ensure that victims and their families are involved in internal investigations and supported in accordance with the SUI policy.
midlands
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 21
The trust should communicate with the victim‟s and perpetrator‟s families immediately after an incident to offer condolences, explain the trust‟s investigative processes and, if appropriate, offer an apology and support. (II/DB/AA)
london
Independent investigation: Peter Freeman, Newton Abbott (2019) — Rec Recommendation Eight
The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved in the investigation.
south_west
Independent investigation: Paul Taylor, Jarrow (2019) — Rec 9
The Trust should ensure that the Duty of Candour Policy provides staff with guidance where criminal justice services are involved.
north_east_yorkshire
Independent investigation: Lee Turner, Barnstaple (2018) — Rec Recommendation 4
The Trust must ensure that when national guidance relating to Duty of Candour (regarding an incident that is also the subject of a serious criminal investigation) is published, local policies and procedures are updated. The Trust must also ensure that staff understand and implement the new policies and procedures.
south_west
Independent investigation: Leanne Unsworth, Burnley (2019) — Rec 6
The Trust should ensure that it has an agreed and consistent approach to Duty of Candour in relation to the involvement and support of service users, families and the victims of any assault/homicide. This approach should take into account national best practice guidance.
north_west
Independent investigation: Kyle Maher, Tooting (2017) — Rec R10
The trust must ensure that they use the systems in place for complying with duty of candour and carry out regular audits to ensure they are meeting the requirements of the act.
london
Independent investigation: Karen Godden, Leicester (2007) — Rec 5
Although the internal investigation team did meet with the family of this MHSU during the course of its investigation, there was no immediate post incident support provided to the family by the MHSU’s care team. Neither was any support offered to the family of Miss K. Today LPT has a …
midlands
Independent investigation: Halimah Ahmed, Derby (2007) — Rec Nine
The Trust Being Open Policy should be revised to incorporate a specific section which offers direct guidance to staff regarding the communication and support that should be offered to both victim and perpetrator families following a homicide committed by a mental health service user known to the service.
midlands
Independent investigation: Ernie Meads, Edmonton, Wood Green, N London (2004) — Rec 5
That Haringey Teaching Primary Care Trust and Barnet, Enfield and Haringey Mental Health Trust review their Serious Untoward Incident Policy in the light of the findings of this report to ensure that the spirit of the National Patient Safety Agency guidance Being Open is fully met.
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 21
The trust should communicate with the victim‟s and perpetrator‟s families immediately after an incident to offer condolences, explain the trust‟s investigative processes and, if appropriate, offer an apology and support. (II/DB/AA)
london
Independent investigation: Carmelita Tulloch, Vauxhall, London (2006) — Rec Recommendation Numbe
The Trust should develop strategies to ensure that condolence; support and advice are offered to the families / loved ones of the victims of homicide without this endangering the police investigation and judicial processes, and that the Being Open Policy (2008) is reviewed as necessary and fully implemented.
london
Independent investigation: Jean Robertson, Sittingbourne (2015) — Rec 2
NHS England must clarify the responsibilities of a Trust in relation to Duty of Candour and Being Open when a serious incident is also being investigated as a serious criminal offence.
south_east
Independent investigation: Jason Dean, Eston, Middlesbrough (2018) — Rec 3
The Trust should ensure there is appropriate application of Duty of Candour in this case and secure assurance that it is applied correctly in all cases of homicide.
north_east_yorkshire
Independent investigation: Harry Messenger, Faversham (2017) — Rec 6
The Trust wide Patient Safety and Mortality Review Group should undertake an audit of the last 12 months of investigations to assure itself that the Trust adheres to Duty of Candour.
south_east
Independent investigation: Brian Marsh, Swindon (2007) — Rec 23
To provide Mrs A with the opportunity to receive the Trust’s findings, recommendations and actions taken from the Mr B serious untoward incident internal investigation report.
south_west
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 8
There is a vital and continuing need for SHFT to re-build trust and confidence with the population it serves. To achieve this end SHFT should continue its move away from a past unresponsive culture and defensive language. Today, SHFT acknowledge the need to balance accountability and responsibility by ensuring that …
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
NHS England investigation into an unofficial call-handling project at South … — Rec 9
Investigations into serious clinical incidents need to be objective and include families from the outset.
south_east
NHS England investigation into an unofficial call-handling project at South … — Rec 4
Transparency within SECAmb should be complete, timely and unequivocal.
south_east
NHS England follow-up report into an unofficial call-handling project at … — Rec 8
Investigations into serious clinical incidents need to be objective and include families from the outset
south_east
Independent investigation into the care and treatment of Mr D … — Rec 6
The Trust should share its internal investigation report with Miss Y’s family at the earliest opportunity.
Cambridgeshire and Peterborough NHS Foundation Trust
east_of_england
Assurance Review: Trust recommendations — Rec 35
Review Niche patient case studies The Trust should review all Niche case studies in priority order to contact patients in respect of Duty of Candour or ensure appropriate investigations have been completed to a high standard and actions have been implemented.
north_west
An independent review of the Level 2 RCA investigation into … — Rec 1
The Trust needs to ensure appropriate application of Duty of Candour in cases of homicide.
south_east
An independent review of the internal investigation and associated action … — Rec 2
NHS England must clarify the responsibilities of a Trust in relation to Duty of Candour and Being Open when a serious incident is also being investigated as a serious criminal offence.
south_east
Not Accepted
An independent review of the care and treatment received by … — Rec R11
The trust should assure itself that all aspects of Regulation 20 of the Health and Social Care Act 2008 are fully understood and implemented, with particular attention paid to paragraphs 3 and 4, which relate to the requirement for written notification to the relevant person(s) of the requirements set out …
north_east_yorkshire
An independent review into the care and treatment of Mr … — Rec 6
The Trust wide Patient Safety and Mortality Review Group should undertake an audit of the last 12 months of investigations to assure itself that the Trust adheres to Duty of Candour.
south_east
An independent investigation into the care and treatment of Patient … — Rec Recommendation 4
The Trust must ensure that when national guidance relating to Duty of Candour (regarding an incident that is also the subject of a serious criminal investigation) is published, local policies and procedures are updated. The Trust must also ensure that staff understand and implement the new policies and procedures.
Devon Partnership NHS Trust
south_west
An independent investigation into the care and treatment of Mr … — Rec 9
Commissioners must liaise with Sussex Police to agree a suitable approach for Trusts to fulfil their Duty of Candour responsibilities when there is an ongoing police investigation.
south_east
An independent investigation into the care and treatment of Mr … — Rec 9
Devon Partnership NHS Trust must ensure that the policy on engaging with families of victims of homicide committed by patients known to mental health services reflects best practice set out in the NHS England (London) Investigation guidance issued in April 2019 on engaging with families after a mental health homicide: …
Mr A , who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust
south_west
An independent investigation into the care and treatment of Mr … — Rec 8
Devon Partnership NHS Trust (DPT) must ensure that local policies clarify how to consider and apply Duty of Candour regarding an incident that is also the subject of a criminal investigation, with the expectation that decisions made should be documented.
Mr A , who was a service-user under Avon and Wiltshire Mental Health Partnership NHS Foundation Trust
south_west
An independent investigation into the care and treatment of mental … — Rec 7
The Trust should ensure a consistent and agreed approach to Duty of Candour in relation to the involvement and support of service users, families, and victims of any assault/homicide, in line with national best practice guidance.
Lancashire and South Cumbria NHS FT
north_west
An independent investigation into the care and treatment of Adult … — Rec Recommendation 13
Being open and involving families in serious incidents There was a lack of clarity about the implementation of new policies and processes in the transition to PSIRF this meant the process was not transparent for families, which led to great distress. The Trust must ensure there is clarity in the …
south_west
An independent investigation into the care and treatment of a … — Rec 10
The Trust must ensure that all communications executing their Duty of Candour responsibilities (including when acting in the spirit of Regulation 20) fulfils all of the requirements of the Regulation.
Mr P in Dorset NHS England has published an independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust
south_west
An independent investigation into the care and treatment of a … — Rec Recommendation 1
The Trust must ensure that it fully executes its Duty of Candour responsibilities and that where there are parallel investigations by other agencies advice is only sought from senior staff about the most appropriate methods of communicating with affected parties.
Cornwall Partnership NHS Foundation Trust
south_west
An independent investigation into the care and treatment of a … — Rec 7
The Trust must ensure that it fulfils its responsibilities under Duty of Candour and that appropriate guidance and oversight is provided to staff to enable them to execute the responsibility appropriately.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
An independent inquiry into the care and treatment of Mr … — Rec R5
The trust should have a clear process in place to ensure that the victims of serious incidents and their families are supported and involved in the trust internal investigation. As a minimum the trust should ensure that the victim’s family: are provided with and consulted on the terms of …
Mr S . At the time of the homicide (2011) Mr S was receiving care and treatment from Somerset Partnership NHS Foundation Trust
south_west
An independent inquiry into the care and treatment of Mr … — Rec 10
Solent and SHFT must ensure that the Duty of Candour policy and procedures are followed in cases where a service user commits a homicide, and that actions taken under this duty are accurately recorded. Compliance should be audited within 3 weeks of any homicide being identified and reported to the …
Southern Health NHS Foundation Trust
south_east
Detention investigations(3)
Assessment of government progress in implementing the report on the … — Rec 18
NHS England should continue to roll out staff training on SystmOne/HJIS, and should make sure that patient consent is consistently recorded by conducting a national case fle audit and ensuring that this is a mandatory feld in HJIS.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 50
I recommend that the Home Office, in consultation with NHS England, draw up explicit guidelines as to: • What informed consent looks like • What information can be shared between all parties in the event that informed consent to the release of clinical information is granted by the detainee.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 6
Given my observations at each of the Heathrow terminals and at Cayley House, Tascor should arrange for refresher training for its staff on their duty of care, and the need for proper and meaningful engagement with detainees.
Immigration Detention
Independent reviews(13)
Jones: Patronising Disposition Review — Rec 14
One specific element of the Public Authority Accountability Bill is a proposed 'duty of candour' for all public officials. Such a duty has already been introduced in the NHS, following Sir Robert Francis' inquiry into Mid-Staffordshire NHS Foundation Trust. In my view, the Hillsborough families' experiences make the case that …
Policing & Security
Harris Review: Deaths in Custody — Rec 86
Following a death there should be a ’Duty of Candour’ upon NOMS and its staff both towards those organisations responsible for managing the post death processes (such as the PPO and the coroner) and the families and friends of the deceased young adult.
Justice & Legal
Paterson Inquiry — Rec 14
We recommend that when things go wrong, boards should apologise at the earliest stage of investigation and not hold back from doing so for fear of the consequences in relation to their liability.
Health & Social Care
IOPC Review — Rec 8
The Home Office should ensure the 'organisational police duty of candour' is designed in such a way to strengthen the IOPC's ability to infer from lack of candour on the part of police officers and staff during IOPC investigations.
Policing & Security
Morecambe Bay Investigation — Rec 24
We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results. Action: the …
Health & Social Care
Morecambe Bay Investigation — Rec 11
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with the duty of candour of professional staff, and incorporate into …
Health & Social Care
Morecambe Bay Investigation — Rec 1
The University Hospitals of Morecambe Bay NHS Foundation Trust should formally admit the extent and nature of the problems that have previously occurred, and should apologise to those patients and relatives affected, not only for the avoidable damage caused but also for the length of time it has taken to …
Health & Social Care
East Kent Maternity Review — Rec 5
The Trust accept the reality of these findings; acknowledge in full the unnecessary harm that has been caused; and embark on a restorative process addressing the problems identified, in partnership with families, publicly and with external input.
Health & Social Care
East Kent Maternity Review — Rec 4
• The Government reconsider bringing forward a bill placing a duty on public bodies not to deny, deflect and conceal information from families and other bodies. • Trusts be required to review their approach to reputation management and to ensuring there is proper representation of maternity care on their boards. …
Health & Social Care
Ockenden Review — Rec LAfL 14.8
Improving Management of Patient Safety Incidents The governance team must ensure their incident investigation reports are easier for families to understand, for example ensuring any medical terms are explained in lay terms as in HSIB investigation reports.
Health & Social Care
Caldicott Review 2013 — Rec 5
In cases when there is a breach of personal confidential data, the data controller, the individual or organisation legally responsible for the data, must give a full explanation of the cause of the breach with the remedial action being undertaken and an apology to the person whose confidentiality has been …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 24
Assessment of systems for reporting adverse events should be part of CQC's registration and assessment of providers. Adverse incident reporting should be a standard component of professional appraisals and revalidation.
Health & Social Care
Cumberlege Review — Rec 1
The Government should immediately issue a fulsome apology on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh.
Health & Social Care
PHSO casework decisions(134)
P-001575 — Mid and South Essex NHS Foundation Trust
Mrs O complained a DNACPR order was placed for Mr M without her knowledge, and he was prematurely discharged without all medication, which she believed contributed to his death.
NHS in England
Oct 2022
P-001956 — Homerton Healthcare NHS Foundation Trust
Mrs Y complained the Trust failed to inform her and her husband about his cancer diagnosis and terminal prognosis, and discharged him without necessary intravenous antibiotics.
NHS in England
Apr 2023
P-002480 — Manchester University NHS Foundation Trust
Mr C complained the Trust prescribed steroids for an eye condition without informing him of all possible side effects, leading to a mental health episode.
NHS in England
Upheld
Nov 2023
P-001147 — Portsmouth Hospitals NHS Trust
Mr H complained the Trust performed a dorsal slit without consent or risk advice, failed to transfer him, and poorly managed his condition, severely impacting his penis functionality and appearance.
NHS in England
Upheld
Oct 2021
P-001680 — Gateshead Health NHS Foundation Trust
There was poor communication, medication errors, incorrect NHS numbers on a DNACPR, and unsatisfactory discharge risk assessment during the patient's inpatient stay.
NHS in England
Dec 2022
P-001751 — Royal United Hospitals Bath NHS Foundation Trust
Mr D complained he was not fully informed of all risks, including major surgery, associated with a polypectomy during a colonoscopy, leading to a perforated colon.
NHS in England
Partly Upheld
Jan 2023
P-001874 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs B complained a junior doctor gave spinal anaesthetic without consent, potentially causing non-epileptic seizures, and a nurse caused pain during a seizure.
NHS in England
Mar 2023
P-001882 — South Warwickshire NHS Foundation Trust
Mrs U complained a DNAR notice was added without her consent, her husband's blood tests and medication were mismanaged, and she was not notified of his death for six hours.
NHS in England
Mar 2023
P-001906 — Moorfields Eye Hospital NHS Foundation Trust
Miss W complained the Trust failed to inform her of cataract surgery risks, the doctor ruptured her eye's posterior capsule without reporting it, and she was not informed about hospital transport.
NHS in England
Mar 2023
P-003282 — Somerset NHS Foundation Trust
Mrs L complained about inadequate consent for a breast biopsy, failure to disclose a complication (a new lump) immediately, and dismissal of her concerns post-procedure.
NHS in England
Partly Upheld
Apr 2023
P-002354 — Liverpool University Hospitals NHS Foundation Trust
Miss A alleged the Trust failed in its duty of candour, lied about her cardiac arrest, gave an adrenaline overdose, and had poor record-keeping, causing distress and misdiagnosis.
NHS in England
Dec 2023
P-003286 — East Sussex Healthcare NHS Trust
Miss H complained the Trust failed to inform her of long-term complications of an endometrial ablation and delayed her hysterectomy for years, causing intense pain and distress.
NHS in England
Partly Upheld
Mar 2024
P-003122 — London North West University Healthcare NHS Trust
Mr A complained the Trust administered lifesaving treatment without his informed consent, causing him to live in torment when he believed he should have died naturally.
NHS in England
Nov 2024
P-003437 — University Hospitals of Derby and Burton NHS Foundation …
Mr Z complained the Trust failed to share information about his wife's cancer progression, delaying the option for alternative treatments and contributing to her premature death.
NHS in England
Upheld
Mar 2025
P-003448 — East Sussex Healthcare NHS Trust
Miss B and Mrs B complained a nurse administered wrong medication, and the Trust delayed notifying the family of Mr B's deterioration, causing distress and affecting their grieving process.
NHS in England
Partly Upheld
Mar 2025
P-004205 — A practice in the Darlington area
Ms O complained the Practice failed to detect or refer her father for a serious ear infection (MOE) and breached Duty of Candour. She also complained about poor complaint handling.
NHS in England
Partly Upheld
Sep 2025
P-004593 — University College London Hospitals NHS Foundation Trust
Mrs R complained about her father's hospital care, including investigations, treatment decisions, consent for a procedure, response to deterioration, and a Do Not Resuscitate decision.
NHS in England
Not Upheld
Jan 2026
P-001782 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mr A complained the Trust provided inappropriate treatment, applied a DNACPR order without consent, communicated poorly, and handled the bereavement notification insensitively.
NHS in England
Feb 2023
P-001791 — Barts Health NHS Trust
Ms R complained about poor communication and delayed morphine administration for her late father during his end-of-life care, causing her distress.
NHS in England
Upheld
Feb 2023
P-001876 — A dental practice in the Kingston upon Thames …
Mr R complained his dental practice cemented a crown without his review and that it was too large, causing embarrassment, eating difficulties, and impacting his confidence.
NHS in England
Upheld
Mar 2023
P-003284 — University Hospitals Birmingham NHS Foundation Trust
The Trust allegedly failed to gain consent for and forced catheterisation on E, causing pain. There were also delays in handling Miss O's complaint.
NHS in England
Upheld
Sep 2023
P-002365 — King's College Hospital NHS Foundation Trust
Mrs D complained a DNACPR notice was placed on her father's records without consent, his resuscitation wishes were ignored, and the Trust failed to escalate her complaint.
NHS in England
Dec 2023
P-002650 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr and Miss U complained their father's DNACPR decision was against his wishes and religious beliefs. They also alleged staff provided inadequate information and were rude and unprofessional.
NHS in England
May 2024
P-002752 — A practice in the City of Derby area
Mrs R alleged the midwife failed to signpost housing support, and the Trust did not help with a birth plan, communicate during labour, get consent, or address her anxiety after a traumatic birth.
NHS in England
Partly Upheld
Jul 2024
P-003285 — Warrington and Halton Hospitals NHS Foundation Trust
Miss E complained staff performed foetal scalp monitoring, additional blood samples, and an episiotomy during her labour without her consent, causing lasting psychological and physical trauma.
NHS in England
Upheld
Jul 2024
P-002892 — Guy's and St Thomas' NHS Foundation Trust
Mr R complained doctors did not inform him of his wife's terminal condition, used jargon, administered inappropriate chemotherapy, and prevented her from receiving treatment abroad, which he believes led to her death.
NHS in England
Aug 2024
P-002990 — University Hospitals Dorset NHS Foundation Trust
Mr D complained about ambulance and hospital delays, misdiagnosis of his wife's brain haemorrhage as a stroke, and poor communication, which he believed contributed to her death.
NHS in England
Partly Upheld
Aug 2024
P-002839 — Barts Health NHS Trust
Mrs R complained about an unconsulted DNACPR order, inadequate nursing care (pain relief, food/drink), misleading information about her husband's deteriorating condition, and denial of family visits.
NHS in England
Upheld
Aug 2024
P-002916 — Barts Health NHS Trust
Ms P complained the Trust failed to prescribe pneumonia medication, provide pain relief/antibiotics, offer suitable food, withdrew antibiotics without consent, and poorly communicated her father's deterioration.
NHS in England
Sep 2024
P-002950 — County Durham and Darlington NHS Foundation Trust
Mrs U complained about poor communication, lack of an overarching care plan, unmet nutrition/hydration needs, and delayed palliative care for her father.
NHS in England
Partly Upheld
Sep 2024
P-002952 — Mid Yorkshire Teaching NHS Trust
Mrs A complained the Trust discharged her husband with uncontrolled diabetes, discussed a DNACPR without proper communication, and misinformed him about his condition.
NHS in England
Sep 2024
P-002945 — Manchester University NHS Foundation Trust
Miss U complained about inappropriate restraint, an unwarned injection, excessive force by security, an invalid sectioning, an inaccurate diagnosis, and not being informed of a needlestick injury or sectioning.
NHS in England
Sep 2024
P-002938 — University Hospitals of Derby and Burton NHS Foundation …
Mrs A complained the Trust issued a DNAR order without family consent, administered incorrect opioid pain relief leading to her husband's death, and failed to explain his care plan.
NHS in England
Sep 2024
P-003093 — East Suffolk and North Essex NHS Foundation Trust
Miss O complained the Trust failed to treat her sister quickly, placed her inappropriately, mismanaged hydration and oxygen, neglected posture, and did not involve family in critical treatment discussions before her death.
NHS in England
Partly Upheld
Oct 2024
P-003027 — Walsall Healthcare NHS Trust
Mr L complained about a lack of follow-up on his partner's cancer diagnosis, poor communication, absence of a care plan, and inadequate personal care. He believed earlier treatment would have saved her life.
NHS in England
Oct 2024
P-003136 — The Royal Wolverhampton NHS Trust
Mr F complained the Trust misdiagnosed him with cancer and provided inappropriate aftercare following surgery, causing distress, pain, and financial impact.
NHS in England
Nov 2024
P-003270 — North Bristol NHS Trust
Mrs L complained the Trust incorrectly recorded she declined a breast screening, didn't send a further invitation, and failed to amend her medical records after her cancer diagnosis.
NHS in England
Partly Upheld
Jan 2025
P-003295 — South Tyneside and Sunderland NHS Foundation Trust
Miss U complained the Trust failed to provide her mother adequate hydration and did not communicate its decision to place a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order.
NHS in England
Upheld
Jan 2025
P-003274 — United Lincolnshire Teaching Hospitals NHS Trust
Ms N complained about delayed oesophagus cancer treatment, lack of information about her brother's prognosis, poor communication, wrong infection information, and unaddressed care wishes.
NHS in England
Jan 2025
P-003335 — East Suffolk and North Essex NHS Foundation Trust
Mrs B complained about various failings in her fertility care, including delayed medication, mislabelled tests, poor communication, cancelled procedures, and the Trust's inadequate complaint handling.
NHS in England
Feb 2025
P-003329 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs T complained about insufficient discussion of non-surgical options, inadequate communication of surgical risks, failure to formally assess her father's capacity, and relying on an outdated scan before surgery. She also complained about the investigation of post-surgery complications.
NHS in England
Partly Upheld
Feb 2025
P-003394 — London North West University Healthcare NHS Trust
Ms E complained the Trust wrongly removed her father's cardiac monitor, failed to treat sores and provide water, and did not notify her of his death, causing profound distress.
NHS in England
Mar 2025
P-003397 — Buckinghamshire Healthcare NHS Trust
Mr E complained about poor care and treatment, including delayed admission, inappropriate medical care, and poor communication during his wife's hospital stay, which he believed contributed to her death. He also criticised the Trust's complaint handling.
NHS in England
Mar 2025
P-003499 — Barts Health NHS Trust
Miss H complained her mother received poor care, including false hope, lack of consent for procedures, missed pneumonia signs, and poor communication, leading to her death.
NHS in England
Apr 2025
P-003517 — University College London Hospitals NHS Foundation Trust
Mrs C complained about a last-minute appointment location change, a rude doctor, and inaccuracies in Mr C's clinical letter, which led to his discharge.
NHS in England
Apr 2025
P-003513 — Somerset NHS Foundation Trust
Mrs U complained about insensitive communication of her surgery outcome, delayed diagnosis change, a wrong treatment plan, an amended consent form, refusal of MRI scans, and obstructive complaint handling.
NHS in England
Apr 2025
P-003522 — Medway NHS Foundation Trust
Miss A complained about her father's inappropriate discharge, delayed/incorrect equipment, inadequate meals, uncommunicated sepsis, unaddressed worsening condition, and poor staff communication.
NHS in England
Apr 2025
P-003550 — University Hospitals of Derby and Burton NHS Foundation …
Mrs R complained about delays in her husband's cardiac arrest management, staff accessing his phone, and poor complaint handling, questioning if better care could have saved him.
NHS in England
May 2025
P-003586 — Lewisham and Greenwich NHS Trust
Miss Q complained Lewisham and Greenwich NHS Trust staff did not respond to her father's deterioration, failed to consult the family about his DNACPR order, and did not inform her of his death upon her arrival at the hospital.
NHS in England
Jun 2025
P-003699 — Sherwood Forest Hospitals NHS Foundation Trust
Mrs A complained the Trust stopped her husband's antibiotics prematurely, poorly monitored fluids, did not support hygiene, gave oral fluids when he was nil by mouth, communicated poorly, and mishandled her complaint.
NHS in England
Upheld
Jul 2025
LGO / SPSO decisions(213)
201507796 — A Pharmacy in the Lanarkshire NHS Board area
Mrs C contacted a pharmacy by phone for an emergency supply of her prescribed medication. She told us the pharmacist refused her request a number of times and that she was treated rudely and asked unreasonable and irrelevant questions. Mrs C complained to us that the pharmacy had not responded …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jan 2017
NIPSO-202003197 — Western Health and Social Care Trust
A woman complained about the treatment her father received in Altnagelvin Hospital, including that he should not have had a catheter inserted while he was dying. We upheld parts of the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2024
NIPSO-202002149 — Northern Health and Social Care Trust
The Northern Trust failed to keep proper records of a patient's food intake, and didn't provide him with insulin after he experienced an episode of hypoglycaemia.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
NIPSO-202003606 — Western Health and Social Care Trust
The Northern Trust should have told a patient and his family that he would not be resuscitated if his heart or breathing stopped.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2025
NIPSO-202005907 — Northern Health and Social Care Trust
The Northern Trust also failed to carry out a proper investigation when the patient complained.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jan 2026
PSOW-202507139 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to respond to the complaint she submitted in April 2025. The Ombudsman found that the Health Board failed to provide Mrs X with a complaint response which the Ombudsman said caused uncertainty and frustration for Mrs X. The Ombudsman decided …
PSOW (Public Services Om…
Health
Jan 2026
PSOW-202507953 — Hywel Dda University Health Board
Ms G complained that Hywel Dda University Health Board failed to issue a response to her complaint, which she made to it in April 2025, regarding the care and treatment provided to her late partner. The Ombudsman found that the Health Board had failed to issue a complaint response. She …
PSOW (Public Services Om…
Health
Jan 2026
20-010-932-report — Hamilton Care Ltd
Summary: Adverse Findings Notice issued because Hamilton Care Ltd failed to provide part of the recommendation to remedy a complaint by the Ombusman.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
20-012-369 — London Borough of Newham
Summary: Ms Z, on behalf of her mother Ms X, complained about the Council’s action in respect of her finances. There is fault by the Council in failing to start a safeguarding investigation at the appropriate time; delay in progressing a safeguarding investigation and failure to ensure Ms X's needs …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
21-009-828 — Devon County Council
Summary: Mr X complained about how the Council communicated with him about the costs of care for his late wife Mrs X. Mr X said he received a large, unexpected bill which caused him a great deal of stress and the Council did not answer his questions about this. We …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-016-410 — The North Northumberland Hospice
We upheld a complaint about end-of-life care. The Care Provider will apologise and review its procedures for record-keeping.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-003-612a — Livewell Southwest (21 003 612a)
Summary: Ms X complains about a lack of care and support provided to her late sister, Ms Y. Ms X says this enabled Ms Y to ingest items she should not have had access to, and that a serious incident report did not answer some of her questions about what …
LGO (Local Government & …
Health
Upheld
Jun 2022
21-016-787 — Kent County Council
Summary: Mr X complains the Council’s care provider, Expertise Homecare (Ashford), failed to meet his late mother’s needs, putting her at risk of harm. His mother did not always receive person centred care and was put at risk of harm by some of her care workers. This caused avoidable distress …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-003-599 — By Your Side Ltd
Summary: Mr X complained on behalf of him and his late mother about how the Care Provider charged them for home care. The Care Provider was at fault for not clearly explaining the care charges, for sending insufficiently detailed invoices and for failing to readvertise for live-in care. It should …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-003-308 — North Yorkshire County Council
Summary: The complainant (Mrs X) said the Council failed to follow the right process when charging her for care services. The Council accepted its fault and offered to waive Mrs X’s outstanding care charges and remind its staff of the need to provide advance information on charging. There is nothing …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
22-004-838 — London Borough of Richmond upon Thames
Summary: Mr Y, complained on behalf of his father Mr X, about the Council’s failure to provide information that long term care would be chargeable. We have not found fault with the Council in how it informed Mr X and his family about care charges. There was fault for sending …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-010-329 — London Borough of Hillingdon
Summary: Miss Y complains about the Council’s actions in relation to a package of home care it commissioned in 2022. The Council upheld some parts of the complaint and Miss Y has received a remedy which we consider to be appropriate. We do not find fault in the other parts …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
23-007-717 — Regent Home Care (West Herts) Limited
Summary: Miss Y complains about the home care provided to her mother, Ms W. The care provider upheld some parts of her complaint, apologised and made service improvements. We have identified some fault in one of the complaints which the care provider has agreed to apologise for and provide a …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
24-007-464 — Bristol City Council
Summary: We will not investigate this complaint about quality of service provided to Mr X by two care providers. The Council has already taken suitable action to remedy injustice caused to Mr X.
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
24-011-103 — Slough Borough Council
Summary: Mr X complained about the Council’s actions linked to reports of a vehicle which belonged to him being abandoned. We found fault as the Council gave out an incorrect telephone number and did not respond to an email from Mr X in a timely manner. This caused Mr X …
LGO (Local Government & …
Environment And Regulation
Upheld
Jun 2025
24-011-650 — Cambridgeshire County Council
Summary: Ms Y complained about how the Council charged her son, Mr X, for a contribution to his care and support and tried to collect a debt from him. There was fault in how the Council communicated with Mr X and Ms Y, with some of the action it took …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-020-292 — Norfolk County Council
Summary: Mr X complained the Council provided incorrect and misleading information about funding his mother’s residential care. We found the Council at fault because of poor communication and delay which caused avoidable distress, frustration and uncertainty. The Council has agreed to apologise and make a symbolic payment to Mr X …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
201204572 — Lothian NHS Board
Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2014
201400370 — Dumfries and Galloway NHS Board
Mr and Mrs C complained to the board about how a bone marrow sampling procedure was carried out on Mrs C. Some weeks after making the complaint Mrs C died. Mr C felt the board's response to their complaint was inadequate, and so he complained to us. We looked at …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2014
201401305 — A Dentist in the Lothian NHS Board area
Mrs C complained that part of her dental work was provided on a private basis without her prior knowledge or consent. She said that she was not given a written treatment plan or cost comparison before the treatment was carried out. The dentist said that Mrs C was given a …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2015
201401586 — Lanarkshire NHS Board
Mrs C was unhappy with a phone consultation she had with an out-of-hours GP. Specifically, Mrs C complained that the GP failed to visit her at home or arrange a visit by another GP, and that the GP terminated the phone consultation and gave an inaccurate account of the phone …
SPSO (Scottish Public Se…
Health
Partly Upheld
Feb 2015
201400888 — Lanarkshire NHS Board
Ms C, who is an advice worker, complained on behalf of her client (Ms A) about the actions of a health visitor in relation to a burn to Ms A's child's arm. The burn was treated at the time by the child's grandmother, who is a healthcare professional. Some weeks …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2015
201404362 — Grampian NHS Board
Mr C complained about the board's handling of his complaint. He had tried to speak to staff about a friend in hospital, and complained that the staff gave him inaccurate information about the board's policy on restrictions on providing information about patients. When the board investigated the complaint they also …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2015
201302557 — Grampian NHS Board
Mrs C's stepfather (Mr A) was diagnosed with advanced bowel cancer in 2011 and had chemotherapy (a treatment where medicine is used to kill cancerous cells). In 2012, he was admitted to Aberdeen Royal Infirmary twice. Mrs C said that during the second admission a doctor told Mr A his …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2015
201404795 — Greater Glasgow and Clyde NHS Board
Mr C complained that a nurse in a prison health centre did not deal with his referral form appropriately. Mr C asked to see the mental health team and he outlined his reasons for his request. A nurse discussed his referral with him and asked questions that Mr C felt …
SPSO (Scottish Public Se…
Health
Not Upheld
Apr 2015
201403639 — A Medical Practice in the Grampian NHS Board …
Miss A was unhappy with the advice she had received on the management of her hypothyroidism (where the thyroid gland produces too little thyroid hormone) with regards to conception and pregnancy. Mrs C, who complained on behalf of Miss A, added that Miss A had complained that she was never …
SPSO (Scottish Public Se…
Health
Not Upheld
Apr 2015
201501220 — A Medical Practice in the Greater Glasgow and …
Ms C attended an appointment at her GP practice with a three-week history of constipation, vaginal bleeding and abdominal pain. Ms C was asked by her GP if she could be pregnant and Ms C said she was not. Ms C carried out a pregnancy test that same evening, and …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201501178 — Tayside NHS Board
Mr C saw a podiatrist because of the deteriorating condition of his foot due to an ulcer. He then had several admissions to Ninewells Hospital as well as being seen as an out-patient. He underwent an artery bypass (a procedure to improve blood flow) from just below the knee to …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500956 — Highland NHS Board
Mr and Mrs C complained to us that the board had failed to inform Mrs C of a diagnosis of diverticulitis (a common disease of the digestive system) that was reached when she had a colonoscopy (examination of the bowel with a camera on a flexible tube) under the Scottish …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500935 — Forth Valley NHS Board
Mr C complained that a prison health centre failed to refer him to a plastic surgery clinic for scar revision. This was in relation to scars on his abdomen which were causing him pain and discomfort. We took independent advice on the complaint from a GP. We were informed that …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500884 — A Dentist in the Lothian NHS Board area
Mrs C sustained nerve damage following dental treatment she received in 2014. She also complained that the dentist failed to respond to the Edinburgh Dental Institute (EDI)'s request for further information after she was referred there for further review. We sought independent advice from a general dental practitioner. We considered …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500696 — Ayrshire and Arran NHS Board
Ms C complained about the care and treatment she received from University Hospital Crosshouse for what she believed was suspected appendicitis. She said she made frequent visits to the A&E department at the hospital and was also admitted to the hospital, but her condition was not reasonably assessed and treated. …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500693 — Ayrshire and Arran NHS Board
Mr C complained about the care and treatment that his late wife (Mrs A) had received at University Hospital Crosshouse across a number of admissions. Mr C was concerned that staff were overly focussed on Mrs A's existing conditions and did not pay enough attention to new symptoms that were …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201500442 — Lanarkshire NHS Board
Mr C complained to us that staff at Monklands Hospital had failed to provide his mother (Mrs A) with appropriate clinical treatment in relation to her nasojejunal (NJ) feeding tube (a tube placed through the nose and into the small bowel to maintain nutrition when patients are unable to take …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201500354 — Fife NHS Board
Mrs C complained to us about the care and treatment provided to her late mother (Mrs A) in the Victoria Hospital. We took independent advice on Mrs C's complaints from a consultant geriatrician and a nursing adviser. Mrs C complained that the action taken in relation to the management of …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201500246 — Lothian NHS Board
Mr C complained to us about the care and treatment his son (Mr A) received when he was admitted to the Royal Edinburgh Hospital under a short-term detention certificate under the Mental Health Act. Mr A has severe autism, learning disabilities and epilepsy. We took independent advice on Mr C's …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201500190 — Tayside NHS Board
Mrs C was referred to Perth Royal Infirmary due to a missing intrauterine system (IUS - a contraceptive device). A scan showed the IUS could be in her abdomen, but she was then found to be pregnant, so no x-ray could be done to confirm the exact location. The pregnancy …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201407891 — Golden Jubilee National Hospital
Mr C complained that the Golden Jubilee National Hospital did not carry out his knee surgery properly and that his aftercare was of a poor standard. He also had concerns about the consent he gave for the procedure as he was under the impression that his named consultant would mainly …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201407889 — A Medical Practice in the Ayrshire and Arran …
Ms C complained about the treatment her father (Mr A) received from the practice over a five month period in 2013. Mr A had been diagnosed with bladder cancer in 2012 and attended the practice on a number of occasions complaining of back pain. Ms C did not feel that …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201407064 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C, who works for a voluntary agency, complained about the care and treatment that her client (Mrs A) had received during admissions to the Southern General Hospital, the Victoria Infirmary and the New Victoria Infirmary. Mrs A was initially admitted after a fall where she broke her arm and …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201406424 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C complained to us about the medical and nursing care her mother (Mrs A) received at the Royal Alexandra Hospital before her death from heart failure. We took independent advice on Ms C's complaints from a nursing adviser and from a medical adviser who is a consultant physician and …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201406354 — A Medical Practice in the Greater Glasgow and …
Mr C was suffering from hoarseness and was referred to hospital by the medical practice for an out-patient appointment at the ear, nose and throat (ENT) department. He was seen by a consultant who identified no suspicious findings and he was discharged back into the care of the practice. Mr …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2016
201802018 — Golden Jubilee National Hospital
Mrs C complained on behalf of her husband (Mr A). Mrs C said Mr A had undergone an operation on his heart, which they had believed would be routine and uncomplicated. Mr A suffered serious complications during the surgery, resulting in a long period of recuperation and life altering consequences. …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2019
201800796 — Fife NHS Board
Mrs C complained to us that nursing staff failed to document her concerns appropriately at a pre-operative assessment before she had a wisdom tooth surgically removed. She said that she told them that she was extremely anxious and that it was agreed that she would be taken first on the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2019
25-002-971 — Telford & Wrekin Council
Summary: We will not investigate Mrs X’s complaint that a carer shouted at her during a telephone call and falsely accused Mrs X of leaving many voicemails. This is because any injustice arising is not significant enough to warrant an investigation.
LGO (Local Government & …
Adult Care Services
Dec 2025
Domestic Homicide Reviews(4)
West Berkshire — recommendation 7
We recommend that NHS England and the Home Office undertake work to examine the impact of the conflicting requirements of confidentiality and the Duty of Candour in the context of the conducting of Domestic Homicide Reviews and Mental Health Homicide Reviews. This case has demonstrated how these duties conflict and …
NHS England | Home Office
NHS England
Epping Forest — recommendation 12.3
The findings of this investigation should be shared with the victim’s next of kin and the service user. A meeting should be offered and facilitated by the Integrated Care Director if required, in order to discuss the findings. The investigation panel was unable to contact the service user due to …
NELFT
North East London NHS …
Northumberland — recommendation 9
The outcome of this investigation should be made available to the patient’s grandparents and an apology offered regarding shortfalls in the provision of appropriate standards of care and treatment.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Wycombe — recommendation 9
The ‘Refusal to Travel to Hospital’ form is to be strengthened with some additional wording to show the signatory understands the risks of not attending hospital.
South Central Ambulance Service
South Central Ambulance Service …
CQC enforcement actions(4)
Fixed Penalty Notice: West Suffolk NHS Foundation Trust
The Care Quality Commission issued two fixed penalty notices, totaling £2,500, to West Suffolk NHS Foundation Trust. This action was taken because the trust did not comply with duty of candour regulations following an incident in October 2018 where a …
Oct 2021
Fixed Penalty Notice: Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
The Care Quality Commission has fined Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust £2,500 for not complying with the duty of candour regulations. CQC issued two fixed penalty notices of £1,250 to the trust because it had not complied …
Jul 2021
Criminal Prosecution: University Hospitals Plymouth NHS Trust
The Care Quality Commission (CQC) prosecuted University Hospitals Plymouth NHS Trust for breaching the duty of candour regulation. The trust admitted it did not disclose details relating to a surgical procedure or apologise following the death of a 91-year-old woman. …
Plymouth
Sep 2020
Fixed Penalty Notice: Bradford Teaching Hospitals NHS Foundation Trust
The Care Quality Commission issued a fixed penalty notice to Bradford Teaching Hospitals NHS Foundation Trust, fining them £1,250. This action was taken because the trust did not comply with the Duty of Candour, a regulation requiring providers to be …
Jan 2019