Elective Surgery Waiting List Disparities
Disparities in elective surgery waiting lists, particularly affecting women, and the lack of financial support for patients to travel.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
40 PFD reports
100 committee recs
1 HSSIB rec
114 CQC actions
1 PPO rec
1 NAO rec
1 PHSO rec
63 PHSO decisions
193 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Prevention of Future Deaths reports(40)
Ronald Perry
Concerns: The coroner noted inconsistent criteria for requesting CT scans depending on the time of day or weekend, creating varying levels of care for patients "out of hours" and posing risks of future deaths.
Response: • The Health Board confirmed that an emergency on-call CT service is provided for life-threatening conditions, with consistent criteria for scans performed at any time. • The Health Board stated … (AI summary)
Responded
Leslie Summerfield
Concerns: The coroner raised concerns about the withdrawal of urgent endoscopy services at Trafford General Hospital, questioning the safety of treating acutely unwell patients requiring such essential procedures at the facility. This led to patient transfers and delays in accessing critical care.
Overdue
David Mostari
Concerns: The coroner noted an inadequate system for ensuring urgent diagnostic tests, such as x-rays and ultrasounds, are performed without delay, particularly for patients admitted at weekends.
Response (D Mostari): • The Trust developed a position statement and action plan. • The Trust is implementing the position statement and action plan to ensure a robust system for urgent diagnostic tests … (AI summary)
Responded
Sandra Wood
Concerns: The NHS Trust does not have facilities for routine CT scans on weekends, and the urgent scan procedure can cause delays, as a required scan was postponed until after the weekend.
Response (sandra wood): • The Trust reiterated to clinical staff the processes in place for 24/7 availability of CT scanning for urgent cases. (AI summary)
Responded
Marilyn Anson
Concerns: Concerns were raised regarding the long wait times for urgent 'hot foot' clinic referrals, which led to patient deterioration. The coroner noted the need for a review of patient prioritisation, resource allocation, and a standardised referral process with clearer guidance for community nurses.
Overdue
Marina Fagan
Concerns: The coroner noted insufficient neurologists nationally, contributing to delays in specialist neurological input, including a lack of out-of-hours on-call neurologists at the admitting hospital and lengthy outpatient waiting times.
Response (Department of Health): • Health Education England (HEE) has consistently invested in commissioning neurology training places. • HEE intends to commission 219 neurology training places in 2016/17. (AI summary)
Responded
Sarah Tyler
Concerns: The coroner noted delays in hospital admissions due to insufficient bed availability. This issue is exacerbated at weekends when fewer patients are discharged, leading to bed blocking.
Response: • The Health Board implemented a process in February 2017 to inform community services when patients known to them attend the Emergency Department. • The Health Board assesses patients waiting … (AI summary)
Responded
Patricia Donovan
Concerns: The coroner noted concerns about repeated cancellations and delays in hip fracture surgery due to insufficient theatre staff and resource availability, which extended beyond recommended guidelines and can lead to serious complications.
Overdue
Terrence George
Concerns: The coroner noted a lack of local guidance in most South West NHS Trusts for gallstone pancreatitis surgery. Urgent cholecystectomy was not prioritised due to competing demands, despite doctors being aware of international recommendations.
Overdue
Kristina Cross
Concerns: The coroner identified significant delays and a lack of reporting on plain radiology due to a shortage of Consultant Radiologists. This meant radiological investigations, crucial for diagnosis and clinical decision-making, were not completed within required timescales or at all.
Overdue
Thomas Curtin
Concerns: The coroner noted the absence of a National NHS England framework for private providers of locked rehabilitation units. This can lead to delays in placing patients with complex needs, who then remain in inappropriate wards while awaiting transfer.
Response (NHS England): • NHS England stated that directly commissioned specialised mental health services, including private providers, are subject to contracts requiring timely referral responses. • NHS England recognised a need to understand … (AI summary)
Responded
Charles Williamson
Concerns: A shortage of appropriate neuro-rehabilitation beds in Greater Manchester prevents early effective rehabilitation, which can increase complications and the risk of death.
Response (the Department of Health and Social Care): • The Greater Manchester Health and Social Care Partnership is working to implement a new model of care for neuro-rehabilitation services. • Work is being undertaken to improve the quality … (AI summary)
Responded
Derek Weaver
Concerns: The coroner identified that delays in transfer and surgery, caused by a surge in referrals and limited capacity, led to surgery being performed during SIRS, which increased the risk of death. There are concerns this risk will recur without the provision of more beds.
Response (Guys and St Thomas NHS Trust): • The Trust implemented a 'consultant of the week' system for thoracic surgery referrals in April 2019. • In October 2019, the management of thoracic surgery beds and urgent transfers … (AI summary)
Response (the Department of Health): • NHS England's national Specialised Commissioning Quality Team undertook peer review and surveillance activities of thoracic services in London. • NHS England and NHS Improvement will maintain oversight to ensure … (AI summary)
Response (NHS England): • NHS England confirmed that regional assurance activities, including peer review visits and annual surveillance, had been undertaken for thoracic services in London. • NHS England noted that Guys and … (AI summary)
Responded
Shirley Nightingale
Concerns: Concerns included a lack of clear systems for OGD management escalation, prioritisation, and follow-up. There was also no system to record rationale or obtain senior clinician agreement when departing from best practice timescales.
Overdue
Brian Murphy
Concerns: Delays in the system for cardiology test referrals resulted in slower completion of tests and postponed patient referrals to the cardiology clinic.
Response (Stockport Clinical Commissioning Group): • The organisation stated that a review of the patient's care pathway found that care was managed appropriately and in a timely manner. • The organisation indicated that no delays … (AI summary)
Responded
James Curry
Concerns: The coroner raised concerns about prolonged waits in the Emergency Department and delays to surgery for elderly patients with hip fractures due to bed and capacity shortages, leading to a lack of orthogeriatric care and non-compliance with NICE guidance.
Response (NHS Greater Manchester): • The Trust increased its trauma and orthopaedics bed base to near pre-pandemic levels. • The Surgical and Medical Division implemented an enhanced bed allocation process for hip fracture patients. … (AI summary)
Responded
Margaret Warwick
Concerns: The coroner identified delays in a patient's hip fracture care, attributing them to a shortage of cardiologists, especially for weekend and out-of-hours assessments, and insufficient theatre and High Dependency Unit bed capacity at the Trust.
Overdue
Kellum Thomas
Concerns: The coroner identified a lack of robust systems for managing essential heart monitoring devices and their replacement, resulting in excessively long waiting lists. Additionally, critical outpatient letters were significantly delayed, hindering timely communication of important medical information.
Overdue
Violet Howard
Concerns: The coroner noted a gap in commissioning arrangements for dermatology services covering inpatients at Royal Oldham Hospital who are from outside the Oldham area, unless they become emergency dermatological cases.
Response (NHS Greater Manchester Integrated Care): • The Oldham Care Organisation has actioned a service level agreement (SLA) with Salford Royal NHS Foundation Trust to address the provision of dermatology services for inpatients. • Learning from … (AI summary)
Responded
Irene Davies
Concerns: The coroner noted extended waiting times for elective surgery due to COVID-19 backlogs, which affected Mrs Davies. Concerns were also raised about ongoing ambulance availability issues in Greater Manchester, leading to delayed urgent responses.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated that the NHS Delivery Plan for Tackling the COVID-19 Backlog of Elective Care was published, with a vision to eradicate waits … (AI summary)
Responded
Maureen Harrop
Concerns: The coroner noted a prolonged A&E stay due to lack of bed capacity and delayed surgery beyond NICE guidelines, which significantly impacted the patient's physiological reserves and overall condition.
Response (NHS England): • The Trust reinstated previous care pathways, increased trauma and orthopaedics bed capacity, and implemented an enhanced bed allocation process. • Processes for managing hip fracture patients awaiting surgery were … (AI summary)
Responded
Ellen MacFarlane
Concerns: The coroner noted significant ambulance delays exceeding 5 hours due to high demand and staff shortages. Additionally, difficulties accessing cardiac tests at District General Hospitals out of hours caused surgical delays for patients with fractured neck of femur, inconsistent with NICE guidance.
Response (Department of Health and Social Care): • The Department of Health and Social Care published a 'Delivery plan for recovering urgent and emergency care services' and provided £200 million in additional funding for ambulance services. • … (AI summary)
Responded
Douglas Nickols
Concerns: The coroner notes that East Surrey Hospital's inability to perform hip fracture operations within the NICE guideline timeframe (on the day of admission or the day thereafter) places patients at increased risk of complications and early death.
Overdue
Holly Mullan
Concerns: The coroner noted significantly increased waiting times for gastroenterology and gynaecology appointments in the NHS post-Covid, which are leading to delays in diagnosis and treatment across England.
Response (NHS England): • NHS England is implementing the Delivery Plan for Tackling the COVID-19 Backlog of Elective Care. • The national rollout of the Getting it Right First Time (GIRFT) Programme is … (AI summary)
Responded
Kathleen Booth
Concerns: The coroner noted a four-day delay in surgery due to NHS-wide understaffing and underfunding, with wards combining elective and emergency work. Patients injured on a Friday faced disadvantages due to limited weekend staffing and experience.
Response (NHS England): • NHS England published the 7-Day Hospital Services Programme in 2013, which introduced clinical standards for acute medical care. • NHS England published the Delivery plan for recovering urgent and … (AI summary)
Response (University Hospitals of North Midlands NHS Trust): • The Trauma Directorate introduced a dedicated fragility fracture theatre list five days per week on 6 November 2023. • The division is preparing a business case to assess if … (AI summary)
Responded
Anthony Williams
Concerns: The coroner identified national shortages of specialist scanning facilities and significant delays in the two-week cancer pathway, leading to delayed diagnoses and treatments, which impacts patient outcomes.
Response (NHS England): • NHS England published guidance on diagnostic imaging reporting turnaround times in August 2023, setting maximum turnaround times for services including PET CT scans. • NHS England published the Delivery … (AI summary)
Responded
Jasbir Pahal
Concerns: The coroner notes the thrombectomy service for stroke patients operates only during limited weekday hours, denying access to this time-sensitive treatment for those suffering a stroke outside these times. This creates a disparity in access based on when a stroke occurs.
Overdue
Gregor Lynn
Concerns: The cost of histological analysis in private treatment may deter patients from crucial diagnostic tests routinely included in NHS care. This disparity poses a risk of future deaths by hindering early cancer detection.
Response (Cambridgeshire and Peterborough): • The Integrated Care Board reviewed its current and previous referral policies for benign skin lesions. • It will signpost NHS GPs to guidance on skin cancer detection and remind … (AI summary)
Response (NHS England): • The Cambridgeshire and Peterborough Integrated Care System (ICS) reminded local GPs of guidance on skin cancers and shared their benign skin lesion policy. • The ICS reminded NHS primary … (AI summary)
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England regarding the issues raised. • The response noted that NHS England had raised the concerns with the relevant Integrated Care System (ICS). … (AI summary)
Responded
Elizabeth Brown
Concerns: The coroner noted significant delays in patients accessing specialist immunology services due to a national shortage of qualified staff and high vacancy levels, which recruitment efforts were not resolving.
Response (NHS England): • NHS England is delivering the Long-Term Workforce Plan to address staffing shortfalls across the NHS. • A workforce distribution review is planned to consider the allocation of immunology posts. … (AI summary)
Responded
James Cockburn
Concerns: The coroner identified significant delays in patients accessing cardiologist appointments and essential diagnostic tests due to high demand and a shortage of qualified professionals. Communication delays between two different trusts, caused by incompatible IT systems, also impacted the timely update of patient records.
Response (NHS England): • NHS England is delivering the Long-Term Workforce Plan and published the Delivery plan for tackling the COVID-19 backlog of elective care. • NHS England has opened over 120 Community … (AI summary)
Response (Greater Manchester Integrated Care): • NHS Greater Manchester ICB has a CVD prevention plan to improve waiting times for cardiology appointments and diagnostic tests. • The Greater Manchester Imaging Network is supporting workforce upskilling, … (AI summary)
Responded
Lorraine Procter
Concerns: The coroner noted significant backlogs for cardiology appointments, leading to patients waiting in excess of 40 weeks for specialist input, which increases the risk of complications and death for those needing timely care.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated a commitment to achieving the NHS Constitutional standard of 92% of patients waiting no longer than 18 weeks from Referral to … (AI summary)
Responded
Noura Hardy
Concerns: The coroner raised concerns that excessively long waiting lists for heart treatment pose a national problem, as a patient's prolonged wait for treatment led to complications from long-term steroid use.
Response (Department of Health and Social Care): • The government has committed to achieving the NHS Constitutional standard of 92% of patients waiting no longer than 18 weeks for treatment by the end of this parliament. • … (AI summary)
Pending
David Curry
Concerns: The coroner noted a significant delay in Mr Curry's urgent surgery due to a lack of theatre capacity, which resulted in a prolonged stent dwell time and an increased risk of post-operative urinary infection and sepsis.
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England, which raised the concerns with the Norfolk and Waveney Integrated Care Board (ICB). • The Norfolk and Norwich University Hospital Orthopaedic Centre … (AI summary)
Responded
Sara Grinnell
Concerns: Extensive delays in contacting a patient for an urgent gynaecology appointment were noted, due to reliance on written correspondence. Re-referrals did not adequately consider previous delays, resulting in a 24-month delay to diagnosis.
Response (Cwm Taf Morgannwg University Health Board): • The Health Board developed an improvement plan for Urgent Suspected Cancer referrals. (AI summary)
Responded
Junior Powell
Concerns: Delays in patient discharge due to a lack of suitable community social care are causing hospital congestion, which in turn delays urgent medical assessment and diagnosis, increasing the likelihood of death.
Overdue
Karen Dack
Concerns: The coroner noted concerns regarding repeated surgery cancellations due to insufficient theatre availability, despite reviews of patient prioritisation. The report indicates that the number of available theatres remains unchanged, posing a risk of similar incidents.
Response (Department of Health and Social Care): • The Trust completed a mortality review and implemented immediate actions, including changes to emergency theatre booking and improvements in documentation. • The Trust is undertaking a Patient Safety Incident … (AI summary)
Responded
Carla Smith
Concerns: The coroner identified significant and persistent waiting list backlogs for gynaecology referrals, which risks patients deteriorating and losing treatment options. There is no system to monitor the progress of patients on these waiting lists, potentially leaving them waiting excessively without review.
Response (Department of Health and Social Care): • The Department committed to reducing patient wait times, including restoring the 18-week Referral to Treatment standard and addressing backlogs in gynaecology. • NHS England is supporting the expansion of … (AI summary)
Responded
Thomas Oldcorn
Concerns: The coroner noted that national targets for waiting times from angiography to surgery were not being met, with current waiting times exceeding the 7-day target due to inadequate resources.
Response (Blackpool Teaching Hospital NHS Foundation Trust): • The Trust recruited a Consultant Surgeon and authorised recruitment for workforce gaps in Theatres and Cardiac Intensive Care. • A dashboard is in place to track urgent cardiac surgery … (AI summary)
Responded
Michael Moore
Concerns: The coroner noted that the NHS does not have the capacity to manage the significant volume of cancer referrals, which results in substantial delays for patients awaiting diagnosis, surveillance, and treatment.
Response (NHS England): • NHS Norfolk and Waveney ICB and Norfolk and Norwich University Hospital will undertake a capacity and demand review to identify service gaps and support recruitment. • A review and … (AI summary)
Responded
Geoffrey Gudgeon
Concerns: The coroner identified capacity issues affecting the timely admission and treatment of stroke patients in Cornwall, noting that only 35% were admitted to a stroke unit within 4.5 hours and only 55% spent over 90% of their time on a stroke unit.
Response (Royal Cornwall Hospitals NHS Trust): • The Trust implemented a Stroke Bed Escalation Plan, increased Stroke Consultant availability, and conducted rapid reviews of in-house data. • A multi-stakeholder discussion took place on 4 March 2026 … (AI summary)
Response (Cornwall Isles of Scilly Integrated Care Board): • The Integrated Care Board (ICB) is leading a system-wide programme of review and improvement for stroke capacity and pathway provision. • A cross-organisational working group has been established to … (AI summary)
Responded
Select committee recommendations(100)— showing 50 strongest matches
#10 —
Recommendation: The national health and care recovery plan must set out a clear vision for what ‘success’ in tackling the backlog will look like, and what patients can expect their care to look like in their local area in the coming …
Response attribution not verified
#20 —
Recommendation: We asked about very long-waiters in different areas and what action NHSE&I was taking to reduce them. It told us that all areas had had the same expectation placed upon them, to attempt to reduce the number of patients who …
Response attribution not verified
#18 —
Recommendation: In September 2021, patients in the worst-performing of NHSE&I’s 42 geographic areas of England were more than twice as likely as patients in the best-performing areas to have been waiting over 18 weeks for elective care. Patients were also more …
Response attribution not verified
#16 —
Recommendation: There are 6 million people on the waiting list for elective care.36 NHSE&I told us it intends to focus on those with the highest clinical need and priority, and especially in the immediate period, those who have waited the longest …
Response attribution not verified
#14 —
Recommendation: The Department and NHSE&I are now managing a large, growing and diverse set of challenges to elective and cancer care on top of the ongoing pandemic. We asked how the Department and NHSE&I expected the accelerated and expanded vaccine booster …
Response attribution not verified
#11 —
Recommendation: The very large numbers of people who have not presented for healthcare, or were not able to obtain it, during the pandemic, as well as those who have already been on waiting lists for long periods of time present a …
Response attribution not verified
#8 —
Recommendation: The C&AG’s Report included two plausible scenarios under which the waiting list will be even longer in 2025 than it was in 2021. One of these scenarios assumed that the NHS would achieve the 30% increase in activity that is …
Response attribution not verified
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and NHS England and NHS Improvement (NHSE&I) about the backlogs and waiting times for elective …
Response attribution not verified
#6 —
Recommendation: For the next few years it is likely that waiting time performance for cancer and elective care will remain poor and the waiting list for elective care will continue to grow. The UK has low numbers of healthcare resources per …
Response attribution not verified
#5 —
Recommendation: Waiting times for elective and cancer treatment are too dependent on where people live and there is no national plan to address this postcode lottery. In September 2021, patients in the worst-performing geographic areas were more than twice as likely …
Response attribution not verified
#11 —
Recommendation: Macmillan Cancer Support and Healthwatch Suffolk submitted evidence to us containing powerful examples of the uncertainty, anxiety and other problems long waits cause patients. Macmillan Cancer Support told us that the impact of cancer care backlogs was being felt by …
Response attribution not verified
#10 —
Recommendation: We shared our concerns about the risks facing the NHS and its ability to deliver the recovery targets and we pressed NHSE on how confident it was that it would meet the target to increase elective activity to 129% of …
Response attribution not verified
#25 — Prioritise longest elective surgery waiting lists and provide financial support for women's travel
Recommendation: Measures to reduce waiting lists for elective surgery should prioritise areas where waiting lists are longest and disparities greatest. The NHS should provide financial support to women to allow them to travel further to access care earlier.
Response attribution not verified
#1 — Northern Ireland's public services remain in crisis across health, education, and justice.
Recommendation: Northern Ireland’s public services remain in crisis. Its health service is under immense pressure, with long waiting lists, a struggling primary care sector and an acute mental health situation, in part due to Northern Ireland’s recent history. There are severe …
Response attribution not verified
#18 — Diagnostic capacity rapidly absorbed by demand, compounded by confusion over surgical hub delivery numbers.
Recommendation: NHSE told us that the additional diagnostic capacity it has created has been quickly taken up by growth in demand and that the NHS was also trying to control non-elective urgent demand.37 We were told however that while it was …
Response attribution not verified
#17 — Diagnostic and surgical hubs show activity below planned levels, failing waiting list targets.
Recommendation: The NAO report found that while CDCs are operational and have provided an increasing proportion of diagnostic activity, NHSE analysis in June 2024 showed that it would not meet waiting list targets due to a shortfall of around 3.6 million …
Response attribution not verified
#11 — Deprived communities and minority groups experience longer elective care waiting times
Recommendation: In July 2025 NHSE started publishing new data alongside the existing monthly Referral to Treatment Waiting Times data that showed that people from deprived communities and minority backgrounds are more likely to be waiting longer than 18 weeks for care …
Response attribution not verified
#10 — Long elective care waiting times pose serious risks to patient health and mortality
Recommendation: We received written evidence that long waiting times can put patients at risk. Evidence from Dr Rob Findlay noted that if it is not known what is wrong with undiagnosed patients then some of them will unexpectedly turn out to …
Response attribution not verified
#9 — Increased diagnostic capacity overwhelmed by surging demand, stalling waiting time progress
Recommendation: NHS England (NHSE) told us that the additional diagnostics capacity it had created had been quickly backfilled by growth in demand. Its progress on achieving the diagnostics recovery target remained stuck, with the number of patients waiting more than six …
Response attribution not verified
#8 — NHS England consistently missed statutory and recovery elective care waiting targets
Recommendation: NHSE’s 2022 recovery plan ambition was to eliminate waits of longer than a year for elective care by March 2025. Within this, NHSE aimed that no one would wait longer than two years by July 2022, that there would be …
Response attribution not verified
#7 — Multiple factors contribute to rising elective care demand and capacity shortfalls
Recommendation: We also received written submissions from a range of individuals and organisations including clinicians and academics, royal colleges representing medical disciplines, care providers, think tanks and charitable organisations. A full list of the written evidence we received is available on …
Response attribution not verified
#1 — Committee gathered evidence on NHS England's elective care waiting time programmes
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department for Health and Social Care (the Department) and from NHS England (NHSE) regarding NHSE’s management of transformation programmes to reduce elective care …
Response attribution not verified
#5 — Require the Department to set out new plans for securing clinical engagement on outpatient transformation.
Recommendation: NHS England’s performance to date has not demonstrated that it can secure the clinical engagement that will be necessary to transform waiting lists. Clinical engagement has worked best when there been close working between national and local clinical leaders, and …
Response attribution not verified
#4 — Require NHSE and Department to set out plans for elective care digital transformation and IT connectivity.
Recommendation: We are not confident that the Department is being realistic about the immense effort needed to reduce NHS elective care waiting times, and see a significant risk that digital solutions are being treated as a ‘cure- all’ as the 10 …
Response attribution not verified
#26 —
Recommendation: Access to NHS services has reduced significantly during the COVID crisis, potentially creating huge pent-up demand, which will add to the substantial waiting lists that existed before the pandemic.77 NHSE&I told us that access to emergency and critical services, such …
Response attribution not verified
#6 —
Recommendation: We recommend that the Department of Health & Social Care and NHSE/I provide an update on what steps they have, individually and collectively, taken and are planning to take to quantify and address the overall impact of the pandemic on …
Response attribution not verified
#5 —
Recommendation: During our session on 30 June 2020, Sir Simon Stevens told us that he “expects” waiting times for and referrals to core health services to “go up quite significantly over the second half of the year.” We also heard from …
Response attribution not verified
#3 —
Recommendation: The pandemic has placed an unprecedented burden on the delivery of core NHS and care services. This has resulted in the delay, suspension or cancellation of services which in turn has inevitably led to a significant increase in waiting times, …
Response attribution not verified
#25 —
Recommendation: We recommend that NHS England, together with ICBs and the new Office for Health Improvement and Disparities (OHID), work together to deliver regional and national coordination as the system tackles the backlog in elective care. If the independent sector is …
Response attribution not verified
#23 —
Recommendation: Ahead of the arrival of the new funding from the Spending Review in Spring 2022, we recommend that Government provides more details on the 100 new community diagnostic hubs, including where they will be placed, who will staff them and …
Response attribution not verified
#1 —
Recommendation: Our key new recommendation is that, by April 2022, the Department of Health and Social Care works with NHS England to produce a broader national health and care recovery plan that goes beyond the elective backlog to emergency care, mental …
Response attribution not verified
#15 —
Recommendation: The number of missing referrals and the size of the waiting list make for a daunting situation when it comes to the needs of patients. Thinking about the recent changes to GPs’ workload to allow them to focus on booster …
Response attribution not verified
#4 —
Recommendation: It will be very challenging for the NHS to focus sufficiently on the needs of patients when it comes to dealing with backlogs, both patients already on waiting lists and those who have avoided seeking or been unable to obtain …
Response attribution not verified
#3 —
Recommendation: The NHS will be less able to deal with backlogs if it does not address longstanding workforce issues and ensure the existing workforce, including in urgent and emergency care and general practice, is well supported. NHSE&I believes it will be …
Response attribution not verified
#2 —
Recommendation: At our evidence session the Department and NHSE&I appeared unwilling to make measurable commitments about what new funding for elective recovery would achieve in terms of additional NHS capacity and reduced patient waiting times. NHSE&I will receive an additional £8 …
Response attribution not verified
#14 —
Recommendation: Based on these estimates the Department of Health and Social Care and NHS England should set out: a) an estimate of what level of additional capacity in NHS cancer services will be needed to address the backlog in cancer services …
Response attribution not verified
#13 —
Recommendation: The Department of Health and Social Care and NHS England must publish a detailed analysis of the extent of the cancer backlog to support the delivery of the elective care recovery plan. The Department should work with NHS England to …
Response attribution not verified
#17 —
Recommendation: Surgical hubs and community diagnostic centres have potential, but success will rely on them being adequately staffed. NHSE currently has limited evidence on hubs’ and CDC’s ability to continue operating when the wider NHS is under significant pressure.36 The Royal …
Response attribution not verified
#16 —
Recommendation: We asked how confident NHSE was about the component programmes in its plan, particularly those aimed at increasing elective and diagnostic capacity. It told us that it did not have strong evidence for some of its programmes at present, but …
Response attribution not verified
#15 —
Recommendation: NHSE’s elective recovery programme includes plans for: • GPs to handle many elective cases previously dealt with by hospital doctors. Instead of referring some patients for elective care, GPs manage them within the 24 C&AG’s Report, paras 7, 1.15; Autumn …
Response attribution not verified
#13 —
Recommendation: We asked NHSE about whether, in its view, this would provide the NHS with sufficient funding, given its previous comments about the scale of the negative impact inflation had had on its budgets.26 The Chief Executive told us that it …
Response attribution not verified
#12 —
Recommendation: The Department has allocated £14 billion to NHS England from 2022–23 to 2024–25 specifically to recover elective and cancer care, comprising £8 billion of resource funding and £5.9 billion of capital funding, as described in the November 2021 Budget and …
Response attribution not verified
#7 —
Recommendation: In July 2022, the Chief Executive of the NHS, wrote to all Chief Executives of NHS trusts, NHS Foundation Trusts and Integrated Care Boards stating that the 62-day cancer backlog target should be a critical priority for the remainder of …
Response attribution not verified
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health (the Department) and NHS England (NHSE) about NHS backlogs and waiting times in England.1
Response attribution not verified
#4 —
Recommendation: NHS England’s elective recovery programme partly relies on initiatives which have potential but for which there is so far limited evidence of effectiveness. NHSE has expanded some programmes because it believes them to be sufficiently promising, but there is currently …
Response attribution not verified
#3 —
Recommendation: NHS funding has increased, but to deliver key priorities such as elective and cancer recovery it will need to be spent in the most cost-effective way. The Department has allocated £14 billion to NHSE from 2022–23 to 2024–25 specifically to …
Response attribution not verified
#2 —
Recommendation: NHS England was over-optimistic about the circumstances in which the NHS would be trying to recover elective and cancer care. In our first report on NHS backlogs and waiting times in March 2022, we reported our concern that “officials are …
Response attribution not verified
#4 —
Recommendation: We recognise the commitment of policy makers and the NHS leadership to restoring core NHS services and the ongoing efforts to manage the backlog. We are also grateful for the hard work of all staff and the use of innovative …
Response attribution not verified
#24 —
Recommendation: Access to care should not be dependent on where you live in the country. Regional and national co-ordination will be necessary to ensure that strategies aimed at tackling the backlog do not have the unintended consequence of increasing health inequalities.
Response attribution not verified
#22 —
Recommendation: We welcome the £2.3bn pledged in the Spending Review to create around 100 new community diagnostic hubs, but we are yet to see detailed plans for their implementation.
Response attribution not verified
NCEPOD recommendations(5)
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
CQC inspection actions(114)— showing 50 strongest matches
Worthing Hospital
The trust must ensure action is taken to improve their compliance with national waiting list targets and that performance data for the trust can be separated to show site performance.
Must Do
Westmorland General Hospital
The trust must take actions to improve referral to treatment waiting time performance in line with national standards.
Must Do
Westmorland General Hospital
The trust must continue to monitor and take action to improve referral to treatment waiting time performance in line with national standards.
Must Do
The Princess Royal Hospital
The trust must ensure they continue to work on meeting their referral to treatment targets for all pathways.
Must Do
St Richard's Hospital
The trust must ensure action is taken to improve their compliance with national waiting list targets and that performance data for the trust can be separated to show site performance.
Must Do
Salford Royal Hospital
The service must take actions to improve referral to treatment waiting time performance in line with national standards.
Must Do
Salford Royal Hospital
The service must continue to monitor and take appropriate actions to improve average length of patient stay, readmission rates and referral to treatment waiting time performance in line with national standards.
Must Do
Royal Sussex County Hospital
The trust must ensure action is taken to improve their compliance with national waiting list targets, and that performance data for the trust can be separated to show site performance.
Must Do
Royal Hallamshire Hospital
The trust should consider methods to improve compliance toward the cancer two week wait targets.
Should Do
Royal Hallamshire Hospital
The trust should ensure it continues to reduce the number of cancelled elective procedures.
Should Do
Royal Hallamshire Hospital
The trust should ensure it continues to reduce the number of cancelled elective procedures.
Should Do
Rochdale Infirmary
The service must continue to monitor and take appropriate actions to improve average length of patient stay, readmission rates and referral to treatment waiting time performance in line with national standards.
Must Do
Princess Royal Hospital
The trust must ensure action is taking to improve their compliance with national waiting list targets. And that performance data for the trust can be separated to show site performance.
Must Do
North Manchester General Hospital
The service should ensure it improves theatre utilisation rates and reduces the number of cancelled operations for non-clinical reasons.
Should Do
North Manchester General Hospital
The trust should ensure it continues to improve their referral to treatment times for admitted pathways.
Should Do
North Manchester General Hospital
The trust must review its systems and processes to monitor and improve the waiting times for surgery.
Must Do
Northern General Hospital
The trust should consider methods to improve compliance toward the cancer two week wait targets.
Should Do
Northern General Hospital
The trust should ensure it continues to reduce the number of cancelled elective procedures.
Should Do
Northern General Hospital
The trust should ensure it continues to reduce the number of cancelled elective procedures.
Should Do
Kidderminster Hospital and Treatment Centre
Continue with plans to improve performance with the national referral to treatment targets.
Should Do
Kidderminster Hospital and Treatment Centre
Improve patients accessing endoscopy services in a timely way.
Should Do
Kidderminster Hospital and Treatment Centre
Continue with plans to improve performance in line with national referral to treatment times.
Should Do
Kidderminster Hospital and Treatment Centre
The trust should ensure there are processes in place to manage the backlog within the endoscopy service.
Should Do
Kidderminster Hospital and Treatment Centre
Continue to improve referral to treatment performance across all specialties.
Should Do
Kidderminster Hospital and Treatment Centre
Continue with plans to improve performance in line with national referral to treatment times.
Should Do
Kidderminster Hospital and Treatment Centre
Improve performance against the national cancer standards for patients on 2 week waits and patients waiting less than 62 days for treatment.
Must Do
Kidderminster Hospital and Treatment Centre
Improve performance against 18-week referral to treatment times, with the aim of meeting operational standards.
Must Do
Kidderminster Hospital and Treatment Centre
Improve performance against the national cancer standards for patients on 2 week waits and patients waiting less than 62 days for treatment.
Must Do
Kidderminster Hospital and Treatment Centre
Improve performance against 18-week referral to treatment times, with the aim of meeting operational standards.
Must Do
Kidderminster Hospital and Treatment Centre
Improve performance against 18-week referral to treatment times, with the aim of meeting operational standards.
Must Do
Kidderminster Hospital and Treatment Centre
Improve the performance for cancer patients receiving their first treatment within 62 days of an urgent GP referral, to be in line with national averages and operational standards.
Must Do
Glenfield Hospital
The trust should ensure that patients waiting for elective and cancer care and treatment receive this in a timely manner.
Should Do
Fleetwood Hospital
The trust should ensure it continues to closely monitor and improve referral to treatment time (RTT) for non-admitted pathways; particularly for thoracic medicine, geriatric medicine and cardiothoracic surgery specialities.
Should Do
Fleetwood Hospital
The trust should ensure it improves referral to treatment time (RTT) for incomplete pathways, in line with operational standards; particularly for thoracic medicine, geriatric medicine, gynaecology and ophthalmology specialities.
Should Do
Fleetwood Hospital
The trust must ensure it acts to reduce the waiting list for children requiring a general anaesthetic in the south region.
Must Do
Fleetwood Hospital
The trust must ensure that it reviews arrangements to admit and treat patients in line with national targets. Waiting times from referral to treatment need to improve particularly in therapy services.
Must Do
Fleetwood Hospital
The trust must ensure that patients wait no longer than 18 weeks from the point of referral to start treatment.
Must Do
Fleetwood Hospital
The trust must develop and embed a process for the timely assessment, monitoring and prioritisation of patients referred for or awaiting transcatheter aortic valve implantation.
Must Do
Ellesmere Port Hospital
The trust must ensure patients waiting to receive treatment after a referral are clinically reviewed and validated.
Must Do
Cumberland Infirmary
The trust should ensure that there is adequate oversight of the harms caused by delays to assessment and treatment in all specialties and consider the impact of health inequalities upon patients who are waiting to receive care. Regulation 17(2)(a)(f).
Should Do
Clatterbridge Hospital
The services should continue to monitor and improve referral to treatment times for all specialities within outpatients.
Should Do
Broomfield Hospital
The trust should ensure people can always access the service when they need it and waiting times for treatment are in line with the England average for all specialities.
Should Do
Royal Papworth Hospital NHS Foundation Trust
The service should continue to work to reduce the number of cancelled operations due to critical care beds not being available.
Should Do
Fairfield General Hospital
The trust must take actions to improve referral to treatment waiting time performance in line with national standards.
Must Do
Fairfield General Hospital
The service must ensure that referral to treatment times for patients and national standards for treatment of patients with suspected cancer are met.
Must Do
Fairfield General Hospital
The service must take actions to improve referral to treatment waiting time performance in line with national standards.
Must Do
Windsor Dialysis Unit
Providetimelyaccesstotheatresinallcaseswheneverrequired.
Should Do
Rochdale Infirmary
The trust must review its systems and processes to monitor and improve the waiting times for surgery.
Must Do
Poole Hospital
Continue to review the theatre capacity and performance to improve referral to treatment performance within 18-week and 52-week wait breaches.
Should Do
Durham Diagnostics and Treatment Centre
The trust should ensure that there are robust systems in place to monitor patients on waiting lists and review waiting times for access to assessment and treatment.
Should Do
PPO death in custody recommendations(1)
PHSO ombudsman recommendations(1)
Health investigations(4)
Assurance Review: Trust recommendations — Rec 42
104 day cancer breach root cause analysis • Ensure all 104 day cancer waiting time breaches are subject to a root cause analysis (RCA) and thematic reviews are acted upon to ensure pathway problems are properly identified and improved. • The Trust should follow the newly released (October 2021) North …
north_west
This Independent Investigation into concerns and issues raised relating to … — Rec 9
The Trust should review the use of Additional Activity Sessions (AASs) in Urology to ensure that they are appropriately managed, effectively utilised to reduce patient backlogs, and do not inadvertently create disincentives for efficient working within core job plans.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Assurance Review: Trust recommendations — Rec 36
Urology pathway priority management • There is a need to redesign follow-up pathways for Urology patients to match capacity and demand to prevent backlogs and balance this with the faster response for new referrals. Clear protocols for long-term active surveillance which ensures cases are appropriately seen at the right intervals …
north_west
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 25
The Trust may well not have the critical mass of patients necessary to provide viable specialised services for sub-groups of individuals with personality disorder (there are ten recognised sub-types of personality disorder, including the ‘borderline’ type). These patients may also continue to be provided for by out-of-area tertiary services.
south_east
Independent reviews(6)
Darzi Review — Rec 28f
Contribute to the nation's prosperity. With the NHS budget at £165 billion this year, the health service's productivity is vital for national prosperity. Moreover, the NHS must rebuild its capacity to get more people off waiting lists and back into work. At the same time, it should better support British …
Health & Social Care
Darzi Review — Rec 28d
Drive productivity in hospitals. Acute care providers will need to bring down waiting lists by radically improving their productivity. That means fixing flow through better operational management, capital investment in modern buildings and equipment, and re-engaging and empowering staff.
Health & Social Care
Darzi Review — Rec 11
Care for cardiovascular conditions is going in the wrong direction. Once adjusted for age, the cardiovascular disease mortality rate for people aged under 75 dropped significantly between 2001 and 2010. But improvements have stalled since then and the mortality rate started rising again during the Covid-19 pandemic. Rapid access to …
Health & Social Care
Darzi Review — Rec 9
Waiting times for hospital procedures have ballooned. The promise is that for most procedures, treatment will start within 18 weeks. In March 2010, there were just over 2.4m on the waiting list, of whom 200,000 had been waiting longer than 18 weeks. Of those, 20,000 had waited more than a …
Health & Social Care
Darzi Review — Rec 5
How long people wait, and the quality of treatment, are at the heart of the social contract between the NHS and the people. The NHS has not been able to meet the most important promises made to the people since 2015. From access to GPs and to community and mental …
Health & Social Care
Darzi Review — Rec 27
It has taken more than a decade for the NHS to fall into disrepair so improving it will take time. Waiting times can and must improve quickly. But it will take years rather than months to get the health service back to peak performance. I have no doubt that significant …
Health & Social Care
PHSO casework decisions(63)
P-001378 — Homerton University Hospital NHS Foundation Trust
Mr Y complained the Trust failed to inform him when surgery recommenced, forcing him to pay £10,000 for private treatment due to the long wait.
NHS in England
Apr 2022
P-001437 — Hampshire Hospitals NHS Foundation Trust
Mr A complained the Trust repeatedly cancelled his discectomies and provided conflicting information about MRI scans, causing prolonged severe physical pain, mental health deterioration, and family distress.
NHS in England
Partly Upheld
Jun 2022
P-003118 — Tavistock and Portman NHS Foundation Trust
Ms D complained about the Clinic's lack of care and significant four-year waiting times for an appointment following an accepted referral.
NHS in England
Nov 2024
P-002331 — Royal Cornwall Hospitals NHS Trust
Mrs C complained the Trust repeatedly cancelled her hip replacement surgery, causing prolonged pain and delaying her breast cancer treatment. She alleged this led to her needing a second hip replacement.
NHS in England
Dec 2023
P-003384 — University Hospitals of North Midlands NHS Trust
Miss C complained University Hospitals of North Midlands NHS Trust failed to assess the urgency of her broken ankle and delayed her treatment for 12 hours, leading to necessary surgery.
NHS in England
Partly Upheld
Feb 2025
P-004711 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mr A complained about delays in receiving hip injections and arranging surgery for his stage four arthritis, leading to extreme, constant pain and worsened mental health.
NHS in England
Jan 2026
P-004691 — Leeds Teaching Hospitals NHS Trust
Mr A complained the Trust sent unexpected documents in a subject access request, including a cancer diagnosis he wasn't aware of, and incorrectly removed him from a knee replacement waiting list.
NHS in England
Jan 2026
P-004563 — Lancashire Teaching Hospitals NHS Foundation Trust
Mr N claims the Trust wrongly required further diagnostic injections for back pain, delaying his procedure and causing prolonged pain and stress.
NHS in England
Jan 2026
P-001102 — Milton Keynes University Hospital NHS Foundation Trust
Miss H complained the Trust delayed radiotherapy for her father's prostate cancer, causing distress and leading him to believe treatment was no longer an option before his death.
NHS in England
Partly Upheld
Aug 2021
P-001205 — County Durham and Darlington NHS Foundation Trust
Mr E complained about delayed kidney stone procedures for his mother, leading to an emergency and her death. He also cited delayed hospice referral and discharge from Parkinson's service.
NHS in England
Upheld
Nov 2021
P-001790 — Shrewsbury and Telford Hospital NHS Trust
Mrs R complained her late sister's condition was misdiagnosed and her urgent cancer referral downgraded, causing treatment delays that ultimately led to her death.
NHS in England
Feb 2023
P-002314 — Nottingham University Hospitals NHS Trust
Mr O complained a consultant delayed knee surgery when his skin was clear, worsening his mobility and leading to him becoming bed-bound.
NHS in England
Nov 2023
P-002307 — Hull University Teaching Hospitals NHS Trust
Mrs A complained the Trust delayed fitting a pacemaker for her father, believing this delay contributed to his fatal stroke.
NHS in England
Nov 2023
P-002501 — Guy's and St Thomas' NHS Foundation Trust
Mr P complained about the Trust's consistent delays in completing Mr E's cardiac surgery and later deeming him unsuitable, failing to offer a second opinion, alleging discrimination.
NHS in England
Mar 2024
P-002571 — North West Anglia NHS Foundation Trust
Mrs O complained she was not referred for a hip operation in February 2022, leading to months of pain, deteriorated mobility, and having to pay for private surgery.
NHS in England
Apr 2024
P-002600 — Dartford and Gravesham NHS Trust
Mrs H complained the Trust repeatedly delayed her priority hip replacement surgery, failed to provide pain relief, and refused transfers, causing severe pain and forcing private surgery.
NHS in England
May 2024
P-003693 — A practice in the South Gloucestershire area
Miss A complained about being wrongly removed from a tonsillectomy waiting list, refused listing by another Trust, and her GP failing to refer or advise on funding.
NHS in England
Jul 2025
P-003724 — The Rotherham NHS Foundation Trust
Mrs K complained that Rotherham and Sheffield delayed her father's heart surgery, causing his condition to worsen and contributing to his death. She also alleged Sheffield failed to inform her of his palliative care status.
NHS in England
Partly Upheld
Jul 2025
P-003949 — University Hospitals Sussex NHS Foundation Trust
Ms W complained about an eight-month waiting time for an appointment for her injured finger, causing her ongoing pain and difficulty with daily activities.
NHS in England
Sep 2025
P-004006 — University Hospitals Birmingham NHS Foundation Trust
Mrs H complained the Trust delayed her bone cancer treatment, leading to the cancer spreading, her neck collapsing, and hospitalisation, causing significant pain and anxiety.
NHS in England
Sep 2025
P-004405 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs O complained the Trust delayed MRI scans, delayed reviewing/treating her husband's seizures, delayed reviewing an MRI, and lacked communication, leading to his condition worsening and dementia diagnosis.
NHS in England
Nov 2025
P-004384 — Leeds Teaching Hospitals NHS Trust
Miss A complained the Trust dismissed her gynaecological symptoms, prescribed wrong medication, delayed a laparoscopy, and failed to provide a timely follow-up, causing prolonged suffering and mental health impact.
NHS in England
Dec 2025
P-004397 — United Lincolnshire Teaching Hospitals NHS Trust
Ms R complained the Trust delayed seeing her for a large hiatus hernia referral in April 2022, leading to worsening health and irreparable oesophageal damage.
NHS in England
Partly Upheld
Dec 2025
P-004448 — A practice in the Gravesham area
Mrs P complained the Practice delayed correctly referring her daughter for ADHD medication between 2022-2024, causing her daughter extreme anxiety.
NHS in England
Dec 2025
P-004416 — North Bristol NHS Trust
A mother complained about delayed cancer diagnosis due to lack of urgency and adherence to suspected cancer pathway timeframes for her son.
NHS in England
Partly Upheld
Dec 2025
P-004590 — Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation …
Mrs Y complained the Trust mishandled her brother's care by sharing other patients' data, confusing his surgery consent, and failing a gallbladder removal, delaying proper treatment.
NHS in England
Jan 2026
P-004584 — Nottingham University Hospitals NHS Trust
Staff decided against operating on her colloid cyst, discharged her, and then handled her complaint poorly, causing distress and necessitating private care.
NHS in England
Upheld
Jan 2026
P-001448 — Barts Health NHS Trust
Mrs C complained the Trust failed to reschedule her cancelled shoulder operation and did not communicate treatment options or the relocation of orthopaedic services.
NHS in England
Jul 2022
P-001486 — Leeds Teaching Hospitals NHS Trust
Mrs A complained two Trusts failed to provide appropriate care for her neck and back issues, including refusing surgical intervention and an MRI scan.
NHS in England
Aug 2022
P-001831 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mr R complained his spinal surgery was postponed twice, he received conflicting messages, and the Trust's complaint response lacked a proper apology or responsibility for the cancellations.
NHS in England
Nov 2022
P-001685 — South Tees Hospitals NHS Foundation Trust
Mr Y complained about a delay in referring his late wife to a cancer trial, believing earlier access might have saved her life, and that the consultant was unaware of the trial.
NHS in England
Nov 2022
P-001997 — University Hospitals Sussex NHS Foundation Trust
Mrs R complained about two postponements of emergency appendectomy surgery, resulting in open surgery, and an inadequate discharge report and complaint response from the Trust.
NHS in England
May 2023
P-002052 — County Durham and Darlington NHS Foundation Trust
Mr I complained the Trust delayed his mother's hip surgery, discussed risks without family present, restricted visits, and notified him of her death by text message.
NHS in England
Jun 2023
P-002678 — A practice in the Norfolk area
The Practice delayed her fertility referral for approximately seven months, causing significant distress and reducing her chances of successful treatment.
NHS in England
Partly Upheld
Jun 2024
P-002658 — A practice in the Manchester area
Miss L complained about a lack of hair loss treatment and specialist referrals from the Practice, and that the Practice removed her from their patient list.
NHS in England
Jun 2024
P-002730 — Mid and South Essex NHS Foundation Trust
Mrs A complained the Trust delayed Mr A's biopsy and mesothelioma diagnosis, failed to address his shoulder pain, and did not meet his nutritional needs.
NHS in England
Not Upheld
Jun 2024
P-002738 — East Kent Hospitals University NHS Foundation Trust
Ms S complained the Trust failed to diagnose her hernia from September 2019, causing years of pain, distress, and anxiety until surgery in May 2022.
NHS in England
Upheld
Jun 2024
P-002810 — Barts Health NHS Trust
Mr R complained the Trust refused to fix his failed pain device and repeatedly cancelled his surgery, causing him prolonged pain, bladder/bowel issues, and increased anxiety.
NHS in England
Jul 2024
P-002813 — A practice in the Sandwell area
Mrs A complained the Practice failed to refer her to orthopaedics in September 2023 and then delayed an urgent referral for two weeks after her April 2024 complaint.
NHS in England
Jul 2024
P-003050 — Nottingham University Hospitals NHS Trust
The Trust unreasonably delayed a sleep study for his son for four weeks, missing an opportunity to diagnose and treat sleep apnoea, which led to brain damage and developmental disabilities.
NHS in England
Oct 2024
P-003250 — NHS England
Miss O complained NHS England failed to promptly reallocate her son a new orthodontist, forcing her to pay £1,500 for private treatment and causing financial hardship and distress.
NHS in England
Dec 2024
P-003334 — University Hospitals Sussex NHS Foundation Trust
Mrs A complained the Ambulance Trust delayed dispatching an ambulance. She also alleged the hospital Trust failed to provide pain relief, delayed surgery, didn't treat a bowel blockage, and moved her husband's body without informing her.
NHS in England
Feb 2025
P-003345 — The Hillingdon Hospitals NHS Foundation Trust
The Trust delayed hip replacement surgery and performed an unnecessary procedure, causing severe pain, mobility loss, and mental health deterioration for Mrs A.
NHS in England
Feb 2025
P-003338 — Royal Free London NHS Foundation Trust
Mrs H complained about significant delays between ENT and audiologist appointments for her son, A, delaying diagnosis and specialist referral, causing hearing deterioration and pain.
NHS in England
Feb 2025
P-003674 — Great Western Hospitals NHS Foundation Trust
Miss A complained the Trust delayed her mother's CT scan, denying the family earlier information on cancer progression and preventing earlier palliative care.
NHS in England
Partly Upheld
Jul 2025
P-003772 — Gloucestershire Hospitals NHS Foundation Trust
Mr F complained two Trusts delayed his urgent heart operation for over six weeks, causing significant stress, anxiety, PTSD, and physical complications.
NHS in England
Aug 2025
P-004701 — An independent provider in the Chelmsford area
Mr R complained that G4S failed to follow up on the second part of his bilateral hernia surgery, causing a significant delay, prolonged discomfort, and poor complaint handling.
NHS in England
Jan 2026
P-004675 — University Hospital Southampton NHS Foundation Trust
Mr G complained the Trust failed to complete an urgent neurology assessment as requested, causing a lost opportunity for better treatment outcomes and frustration with complaint handling.
NHS in England
Upheld
Nov 2025
P-001814 — Hampshire Hospitals NHS Foundation Trust
Mr U complained about the delayed hernia operation, lack of ESAC access, poor communication about his surgical list, and a 20-day delay in treatment, causing severe pain and risk.
NHS in England
Feb 2023
P-001795 — East Suffolk and North Essex NHS Foundation Trust
Mr F complained the Practice missed signs of his wife's brain tumour and the Trust delayed radiotherapy and chemotherapy, potentially affecting her chances of survival.
NHS in England
Feb 2023
LGO / SPSO decisions(193)
201201233 — Lanarkshire NHS Board
Mrs C was referred to a hospital gynaecology clinic with a vaginal prolapse (a condition when one or more of the pelvic organs slips down from its normal position). After she was first seen, she was given an ultrasound scan (a scan that uses sound waves to create images of …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2013
NIPSO-17834,21521 — Northern Health and Social Care TrustBelfast Health and …
We recommended that the Northern Health Trust apologise to a complainant after our investigation found failings in the care and treatment of her baby son and its handling of a Serious Adverse Incident (SAI) investigation.
NIPSO (NI Public Service…
Health & Social Care
Jan 2021
NIPSO-202001154 — Northern Health and Social Care Trust
A man claimed the Belfast Trust removed him from an in-patient waiting list because he had complained about one of its surgeons. Our investigation found no evidence to support this view.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Feb 2024
PSOW-202201496 — Swansea Bay University Health Board
Mr D complained that he had waited a long time for orthopaedic surgery and that his understanding of how he would be treated was not managed well regarding the pre-operative assessments. The waiting time for orthopaedic surgery at the Health Board is more than 4 years. The Health Board had …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202200425 — Swansea Bay University Health Board
Mrs C complained on behalf of her husband Mr C, that he had waited a long time for orthopaedic surgery and that their understanding of how he would be treated was not managed well regarding the pre-operative assessments. The waiting time for orthopaedic surgery at the Health Board is more …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202200361 — Swansea Bay University Health Board
Mrs B said that she had waited a long time for orthopaedic surgery and that her understanding of how she would be treated was not managed well regarding the pre-operative assessments. The waiting time for orthopaedic surgery at the Health Board is more than 4 years. The Health Board had …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202207270 — Betsi Cadwaladr University Health Board
Mrs B complained about her husband, Mr B’s, care and treatment by Betsi Cadwaladr University Health Board (“the Health Board”). Mr B went to the Emergency Department (“the ED”) at Wrexham Maelor Hospital in April 2022 with urinary retention. My investigation considered whether his symptoms should have led to an …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202504991 — Cardiff and Vale University Health Board
Ms A complained that the Health Board failed to adhere to the Urgent Suspected Cancer pathway and denied that she was on this pathway. At assessment, it was found that the Health Board failed to apologise to Miss A for misinforming her of the nature of her referral to Gynaecology. …
PSOW (Public Services Om…
Health
Nov 2025
201004712 — Highland NHS Board
In early 2011, Mr C complained to the board about the length of time he was told he would have to wait on the waiting list for a psychological assessment. He had already been on the waiting list for over nine months and was told it would be another eight …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2011
201101077 — Lothian NHS Board
Mr C first visited his GP in September 2009 with pain and swelling in his testicles and was referred to the urology team at the Western General Hospital. He was placed on a waiting list for treatment. He was seen in January 2010 by two specialists who could not agree …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2012
201100716 — Lothian NHS Board
Mr C complained about the treatment he received from the board for two hernias. He said that a surgeon failed to correctly interpret his scan results, as he failed to identify one of the hernias. However, we found that the surgeon had interpreted the scan correctly and had identified the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jan 2012
201102499 — Lothian NHS Board
Mrs C had worsening hearing loss in both ears, with narrow ear canals that made use of in-ear hearing aids painful and intolerable. She complained that the board failed to refer her to the correct consultant at the right time, and that there was an unreasonable delay of a year …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201202345 — Lothian NHS Board
Mrs C complained that she experienced an unreasonable delay in receiving appointment notification letters from the board. After she was referred to a respiratory clinic by her GP, the board wrote inviting her to an appointment at the clinic. Mrs C did not receive this letter until after the time …
SPSO (Scottish Public Se…
Health
Upheld
May 2013
201204300 — Lothian NHS Board
Ms C's dentist referred her to the board's dental institute for treatment to remove the roots of a broken wisdom tooth. Ms C complained that there was unacceptable delay in providing an appointment at the institute; and that the lack of communication about the waiting time was unreasonable. After investigating, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2013
201303020 — Tayside NHS Board
Shortly after being placed on the waiting list for a day surgery procedure in hospital, Mr C had a phone call offering him an appointment for the following week. He did not receive the pre-operative information leaflet in the post until two days after the surgery. On the day of …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2014
201400591 — Lanarkshire NHS Board
Ms C complained that after her GP referred her to orthopaedics (the specialty for conditions of the musculoskeletal system) at Wishaw General Hospital, she was inappropriately allocated to podiatry (specialising in disorders of the foot, ankle and lower limb). She had previously attended private podiatry appointments with no improvement to …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2014
201305717 — Grampian NHS Board
Mrs C complained on behalf of her sister-in-law (Mrs A) that the board cancelled Mrs A's facial reconstruction surgery at Aberdeen Royal Infirmary, and did not provide a reasonable explanation for this. From what Mrs C described, this was clearly an upsetting experience for Mrs A. We looked at information …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2014
201303993 — Ayrshire and Arran NHS Board
Mr C had suffered prostate problems since his forties and his prostate health was regularly monitored. Until 2011, the tests had shown that although his prostate was enlarged, he was not suffering from cancer. Early in 2011, Mr C's blood test results began to indicate that he might have prostate …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2014
201303988 — Greater Glasgow and Clyde NHS Board
Mr C complained that he waited too long to see a prison dentist after a crown fell out. He said that he had twice asked to see the dentist and had explained that he was suffering some pain. In response to Mr C's complaint, the board said that they did …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2014
201303371 — A Medical Practice in the Greater Glasgow and …
Mr C complained on behalf of his father (Mr A) who lives in a care home. Mr C was unhappy that Mr A's GP did not visit his father there, but instead spoke to care home staff by phone. He was also unhappy with the GP's responses to his complaint …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2014
201303182 — Western Isles NHS Board
Mr C, who is a solicitor, brought a complaint on behalf of his client (Mrs A) about the service she received after her GP referred her to a psychiatric department. Mrs A complained that the board failed to meet their targets and that her treatment did not meet any reasonable …
SPSO (Scottish Public Se…
Health
Not Upheld
Nov 2014
201500357 — Tayside NHS Board
Miss C raised a number of issues about the time taken by the health board to arrange her appointment for day surgery and that, when it eventually took place, it was outwith the timescales for the Treatment Time Guarantee (TTG) of 12 weeks. Miss C also mentioned that she had …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201405122 — Lanarkshire NHS Board
Mrs C complained about a delay in providing treatment in the ear, nose and throat (ENT) clinic at Wishaw General Hospital. Her GP referred her with a suspected acoustic neuroma (a benign tumour on one of the nerves connecting the inner ear to the brain) and she was frustrated at …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2015
201502592 — Greater Glasgow and Clyde NHS Board
Ms C complained about a delay in arranging surgery for her child (Miss A), who suffered from malocclusion (a misalignment of the teeth and jaws) and chronic facial pain. A treatment plan was agreed for Miss A's malocclusion, including a period of braces followed by maxillofacial surgery (surgery affecting the …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201502517 — A Medical Practice in the Highland NHS Board …
Mrs C complained that the practice cancelled an important appointment with the practice nurse without giving her notice. Mrs C moved to a different practice, and she complained there was delay in sending her medical records to the new practice. We found that the practice could have told Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201501942 — Lothian NHS Board
Mr C complained about the length of time he had to wait for surgery for prostate cancer and said that the board did not provide treatment in line with the national waiting time targets. We took independent advice from a medical adviser. We found that the GP referral for Mr …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201501397 — Lothian NHS Board
Mr C complained on behalf of his partner (Miss A) about the delay in her parathyroid surgery (surgery to remove glands next to the thyroid which secrete a hormone that regulates calcium levels in a person's body), and the board's communication with them about this. Mr C said the consultant …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201507972 — Highland NHS Board
Mr C complained about the time he had to wait for a gastroscopy procedure (a procedure where a thin, flexible telescope called an endoscope is used to look inside the gullet and stomach) at Raigmore Hospital. Mr C was referred for the procedure by his GP after he complained of …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2016
201507774 — Lanarkshire NHS Board
Mr C complained about a delay in being referred for psychology treatment. He was referred to the community mental health team and was seen initially by a consultant psychiatrist and a community psychiatric nurse (CPN). He continued to see the CPN over the following months but it was deemed that …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2016
201508812 — Western Isles NHS Board
Mr C complained about the care his late wife (Mrs A), who suffered from diabetes, received from the board. In particular he complained that when a home visit was made by a district nurse, his wife's podiatry appointment was not brought forward by the board. During our investigation we took …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201508596 — Tayside NHS Board
Mr C complained about delays and communication in relation to his wife (Mrs A)'s hip-replacement surgery at Ninewells Hospital. After taking independent advice from a consultant orthopaedic surgeon, we did not uphold Mr C's complaints. The advice we received was that while Mrs A's patient journey had been a long …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2017
201608063 — Golden Jubilee National Hospital
Mr C complained about the care and treatment provided to his late wife (Mrs A) at Golden Jubilee National Hospital. Mrs A had been diagnosed with bladder cancer by another health board, but before being able to receive treatment for the cancer had suffered a heart attack. She was referred …
SPSO (Scottish Public Se…
Health
Partly Upheld
Sep 2017
201607116 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained that after being put on the waiting list for a transurethral resection of the prostate (surgery used to treat urinary problems caused by an enlarged prostate), he was not given an appointment within the 12 week treatment time guarantee timescale, and that he was not updated about …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2017
201608877 — Fife NHS Board
Mr C complained about the length of time it had taken the board to provide him with treatment for varicose veins. Mr C was referred to vascular surgery at Victoria Hospital by his GP. Around four months later he saw a vascular consultant who said that he needed a special …
SPSO (Scottish Public Se…
Health
Partly Upheld
Feb 2018
201700482 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C complained that the board failed to provide him with clinic appointments within a reasonable timescale. He also raised concern that the board failed to provide him with adequate notice of the cancellation and rescheduling of appointments, and he was unhappy with the board's handling of his complaint. The …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2018
201609412 — Lanarkshire NHS Board
Mrs C, who is an advocacy and support worker, complained on behalf of her client (Mrs A). Mrs A was unhappy about delays in getting confirmation of an appointment with a consultant ophthalmologist (a doctor who deals with injuries and conditions in and around the eye). Mrs A was also …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2018
201708551 — Tayside NHS Board
Mrs C was referred by her GP to the orthopaedic department (the area of medicine which deals with the musculoskeletal system) at Ninewells Hospital for consideration of knee replacement surgery. However, there were problems with the communications from the board which resulted in her missing a scheduled out-patient clinic appointment. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2018
201700671 — Ayrshire and Arran NHS Board
Mr C attended University Hospital Crosshouse after sustaining a tear in the anterior cruciate ligament (a ligament in the knee) and damaged cartilage (connective tissue). Mr C complained that the board took too long to provide appropriate treatment following a referral from his GP, failed to provide a reasonable standard …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
201705257 — Tayside NHS Board
Mrs C complained about the care and treatment she received from Ninewells Hospital regarding a delay in physiotherapy and the board's handling of her complaint concerning the matter. We took independent advice from a consultant obstetrician and gynaecologist (a doctor who specialises in childbirth and the female reproductive system). We …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2018
201804379 — Tayside NHS Board
Ms C complained that Ninewells Hospital failed to provide her with reasonable care and treatment when she was admitted for investigations by the gastroenterology (branch of medicine which deals with disorders of the stomach and intestines) team. We took independent advice from a consultant gastroenterologist. We found that the treatment …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2019
201900596 — Grampian NHS Board
Ms C complained that the board delayed in arranging the surgery she needed. She was entered onto the list for surgery at a gynaecology (medicine of the female genital tract and its disorders) out-patient clinic, but said that she was told months later that they were only carrying out surgery …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2020
201810152 — Tayside NHS Board
C was referred to the board's urology service (specialists in the male and female urinary tract, and the male reproductive organs) via an urgent referral due to suspected cancer. C was diagnosed with transitional cell carcinoma (a type of cancer that typically occurs in the urinary system). C underwent laparoscopic …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2021
201908887 — Highland NHS Board
C complained on behalf of their child (A) who has a background of low mood and anxiety. C complained about the assessments of A by two paediatric consultants. C also complained that the Child Adolescent Mental Health Service (CAMHS) unreasonably rejected referrals from A’s GP due to social work’s involvement …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2021
201810251 — Highland NHS Board
C complained that the board failed to provide their child (A) with orthognathic treatment (orthognathics is a specialist subset of dentistry which involves surgical correction of growth issues with the jaw and lower face) within a reasonable timescale. A's teeth were overcrowded to the extent that they caused pain in …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2021
201907379 — Lothian NHS Board - Acute Division
C complained about delays in treatment that was meant to be provided to their late spouse (A). They told us that A had been referred to the board from another area for heart surgery, but that this took so long to arrange, A's condition deteriorated to a point that surgery …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2022
202004806 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about their waiting time for hip replacement surgery. C was initially added onto the waiting list for surgery but was later removed after C advised the board of their personal circumstances. A couple of months later, C was added back onto the waiting list for surgery but, after …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2022
202009234 — Fife NHS Board
C complained to the board on behalf of their partner (A) about the length of time taken to arrange a lumbar puncture test (LP, a procedure used to collect a sample of fluid from the spine) following assessment by a neurologist (specialist of the nerves and the nervous system). C …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2022
202302835 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment received by their young child (A). A had a complex congenital (from birth) heart condition. C complained to the board after A received heart surgery, which had been part of the treatment planned for A. C complained that the board did not reasonably …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2024
202303181 — Forth Valley NHS Board
C complained about delays in the care and treatment provided to their spouse (A) who was diagnosed with lung cancer following an abnormal chest X-ray. C said that there was a delay in A being provided with a CT scan result by the respiratory consultant, and a further wait to …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2025
202311619 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the lack of care and treatment that the board provided in relation to not being recalled for a colonoscopy. C had undergone regular colonoscopies to monitor disease progression. C was not recalled when the next colonoscopy was due. The COVID-19 pandemic led to suspension of services with …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025