Emergency contingency plans
Lack of pre-existing contingency plans for emergencies (e.g., pandemics), leading to a scramble and flawed early scheme design.
Source spread
Where this theme appears
This theme appears across 28 independent accountability sources, so the source mix matters as much as the headline total.
315 inquiry recs
160 PFD reports
825 committee recs
32 HSSIB recs
172 CQC actions
21 HMICFRS recs
4 ICIBI recs
35 PPO recs
10 IOPC recs
62 NAO recs
38 IMB recs
2 IMB reports
1 patient safety alert
8 Scottish FAIs
3 Article 2 learning points
10 detention investigation recs
45 DHR recs
29 PHSO decisions
80 LGO/SPSO decisions
3 CJINI reports
25 DSA service inquiries
7 ISC reports
1 CQC enforcement action
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(315)— showing 50 strongest matches
88 — Evacuation routes that avoid distressing scenes
Recommendation: Routes for evacuation away from an accident should take into account the need to avoid distressing scenes (para 2.11).
Unknown
87 — Faster earthing and isolation of traction current
Recommendation: Consideration should be given to means of speeding up the process of earthing and isolation of traction current following an accident on an electrified section of line (para 2.15).
Unknown
82 — Review protocols between Railtrack, BTP and HMRI
Recommendation: Existing protocols between Railtrack, BTP and HMRI should be reviewed in the light of the above Recommendations (para 15.24).
Unknown
53 — Practical exercises to prove passenger evacuation standards
Recommendation: Standards for evacuation of passengers should be proved by practical exercises using typical groups of passengers and train crew, and repeated on a regular basis to be approved by HMRI (para 11.11).
Unknown
47 — Internal doors that open easily in a crash
Recommendation: The design of coaches should be such that internal doors can be easily opened in a crash situation, in darkness and irrespective of the attitude of the vehicle; and that hammers intended for breaking windows can be easily located in …
Unknown
44 — Review of internal safety features in passenger vehicles
Recommendation: A review should be carried out by ATOC, with input from all interested bodies, on the ways in which internal safety features may be modified and standardised to provide the best practicable means of emergency exit under accident conditions, including …
Unknown
14 — National procedures on failure of train-borne safety equipment
Recommendation: Clear procedures for steps to be taken on failure of any train-borne safety equipment should apply nationally, subject only to such company variation as is fully justified (para 15.11).
Unknown
4 — Driver training in abnormal situations
Recommendation: Driver training should include driving in abnormal situations permitted by the Rules and specifically driving with AWS isolated to the extent so permitted, including the use of simulators (para 16.4).
Unknown
106 — Emergency training part of the SMS
Recommendation: The operator’s system for emergency training and its enforcement should form part of its SMS (para 20.64).
Unknown
105 — UKOOA guidelines for emergency training
Recommendation: The UKOOA guidelines for offshore emergency safety training on installations should be a minimum requirement for survival, fire-fighting and other forms of training detailed therein for the relevant personnel employed offshore. Personnel who have not met the requirements of these …
Unknown
104 — Lists of personnel on board
Recommendation: Operators should maintain lists of personnel on board by alphabetical order and also by reference to the names of contractors whose personnel are represented on board. These lists should be updated for every movement of personnel and copied immediately to …
Unknown
103 — Reporting precautionary musters
Recommendation: The circumstances of all precautionary musters and evacuations should be reported by operators to the regulatory body (para 20.62).
Unknown
102 — One muster per tour of duty
Recommendation: All offshore staff should attend one muster per tour of duty (para 20.62).
Unknown
101 — UKOOA guidelines for drills and exercises
Recommendation: Offshore emergency drills and exercises should be carried out in accordance with the UKOOA guidelines for offshore emergency drills and exercises on installations (paras 20.61 and 20.64).
Unknown
100 — Drills and exercises part of the SMS
Recommendation: The operator’s system for emergency drills and exercises should form part of its SMS (paras 20.61 and 20.64).
Unknown
97 — Command organisation part of the SMS
Recommendation: The operator’s formal command organisation which is to function in the event of an emergency should form part of its SMS (para 20.59).
Unknown
77 — Helicopter flight following system
Recommendation: Operators should adopt a flight following system for determining at short notice the availability and capacity of helicopters in the event of an emergency. This system could be either a system operated by the individual operator or a North Sea-wide …
Unknown
76 — Immediate analysis without waiting for legislation
Recommendation: The regulatory body should ask operators which have not already done so to undertake an evacuation, escape and rescue analysis forthwith, without waiting for legislation. The timetable for completion of this analysis should be agreed between the regulatory body and …
Unknown
75 — Specific matters the analysis must cover
Recommendation: In particular the analysis should specify:- (i) The formal command structure for the control of an emergency affecting the installation; (ii) The likely availability and capacity of helicopters, whether in-field or otherwise, for the evacuation of personnel; (iii) The types, …
Unknown
74 — Content of the analysis
Recommendation: The analysis should specify the facilities and other arrangements which would be available for the evacuation, escape and rescue of personnel in the event of an emergency which makes it necessary or advisable in the interests of safety for personnel …
Unknown
73 — Evacuation, escape and rescue analysis
Recommendation: Operators should be required by regulation to submit to the regulatory body for its acceptance an evacuation, escape and rescue analysis in respect of each of its installations (para 20.9).
Unknown
72 — Shutdown in emergency on connected installation
Recommendation: Operators should be required by regulation to institute and review regularly a procedure for shutting down production on an installation in the event of an emergency on another installation which is connected to the first by a hydrocarbon pipeline where …
Unknown
71 — Review of pipeline emergency procedures
Recommendation: Operators should be required by regulation regularly to review pipeline emergency procedures and manuals. The review should ensure that the information contained in manuals is correct, that the procedures contained are agreed with those who are responsible for executing them …
Unknown
70 — Availability standards for protective systems
Recommendation: Where a regulation imposes a requirement for a major emergency or protective system, such as a fire deluge system, it should be required that the operator should set acceptance standards for its availability (para 19.199).
Unknown
69 — Immediate review of emergency systems
Recommendation: The regulatory body should ask operators which have not already done so to review forthwith the ability of emergency systems to withstand severe accident conditions (para 19.191).
Unknown
68 — Studies on emergency system vulnerability
Recommendation: Studies should be done to determine the vulnerability of emergency systems to severe accident conditions and to enhance their ability to survive such conditions (para 19.190).
Unknown
67 — Standardisation of status lights and alarms
Recommendation: The regulatory body should work with the industry to achieve standardisation of status lights and of alarm systems for emergencies (para 19.194).
Unknown
65 — Emergency systems in the Safety Case
Recommendation: The ability of emergency systems to survive severe accident conditions should be a feature of the Safety Case (para 19.189).
Unknown
64 — Survivability of emergency systems
Recommendation: The regulations and related guidance notes should promote an approach to emergency systems:- (i) which provides to a high degree the ability of these systems to survive severe accident conditions (paras 19.188-189); and (ii) which applies to communications systems the …
Unknown
63 — Radio Room in the TSR
Recommendation: It should be required by regulation that a Radio Room with facilities for external communications should be located in the TSR (para 19.179). On existing installations where the Radio Room is not in the TSR, these facilities should be in …
Unknown
62 — Facilities for control of emergencies
Recommendation: It should be required by regulation that there should be available within the TSR certain minimum specified facilities for the monitoring and control of an emergency under hostile outside conditions (paras 19.178 and 19.182). These facilities should be in the …
Unknown
61 — Studies on breathable air in the TSR
Recommendation: Studies should be carried out with the objective of assisting designers in predicting the breathability of air in a TSR where its external fire wall is subjected to a severe hydrocarbon fire (para 19.163).
Unknown
60 — Immediate assessment of smoke ingress
Recommendation: The regulatory body should ask operators which have not already done so to carry out forthwith an assessment of the risk of ingress of smoke or gas into the accommodation; and to fit smoke and gas detectors and implement ventilation …
Unknown
59 — Emergency lighting and signs
Recommendation: It should be required by regulation that escape routes are provided with adequate and reliable emergency lighting and with photoluminescent direction signs (para 19.175).
Unknown
58 — Escape routes to remain passable
Recommendation: The regulations and related guidance notes on escape routes should recognise that it may not be practicable to protect escape routes against all physical conditions; and accordingly should be based on the objective that they should remain passable (para 19.174).
Unknown
57 — Ventilation intakes and detectors
Recommendation: For the purpose of maintaining breathable air within the accommodation, it should be required by regulation that the ventilation air intakes should be provided with smoke and gas detectors and that on smoke or gas alarm the ventilation and dampers …
Unknown
55 — Regulations on accommodation and escape routes
Recommendation: Provisions should continue to be made by regulations supported by guidance notes as to the construction of the accommodation; and as to escape routes and embarkation points (para 19.166).
Unknown
51 — Fire water deluge survivability
Recommendation: The ability of the fire water deluge system, including the fire pump system, to survive severe accident conditions should be a feature of the Safety Case (para 19.100).
Unknown
48 — Vulnerability of emergency shutdown valves
Recommendation: Studies should be done to determine the vulnerability of ESVs to severe accident conditions and to enhance their ability to survive such conditions (para 19.43).
Unknown
47 — Emergency shutdown valve activation
Recommendation: The arrangements for the activation of the emergency shutdown valves (ESVs), and of SSIVs if fitted, on pipelines should be a feature of the Safety Case (para 19.42).
Unknown
45 — Studies on inventory and pipeline connections
Recommendation: Studies should be carried out with the following objectives:- (i) To explore the feasibility of dumping in an emergency large oil inventories, such as those in the separators, in a safe and environmentally acceptable manner, so as to minimise the …
Unknown
7 — Safety Case specification of TSR and escape
Recommendation: In connection with the above the Safety Case should specify the following:- In respect of the TSR- — its function — the conditions which constitute its integrity — the conditions for integrity of its supporting structure — the events in …
Unknown
6 — Temporary Safe Refuge as accommodation
Recommendation: The TSR should normally be the accommodation (paras 19.156 and 19.161). In the case of existing installations any requirement for the upgrading of the accommodation, escape routes and embarkation points should be determined on the basis of the Safety Case …
Unknown
5 — Design accidental events and acceptance standards
Recommendation: For the purposes of the demonstration referred to in para (iii) of recommendation 4, the accidental events are to be identified by the operator. A design accidental event is an event which will not cause the loss of any of …
Unknown
16 — Emergency checklists under the ISM Code
Recommendation: We recommend that the checklists provided for by the ISM Code should cover all reasonably foreseeable emergency procedures and that they should be readily available to the master or skipper at all times.
Unknown
9 — Statutory duty for Thames search and rescue
Recommendation: We maintain the recommendation made by the TSI that a statutory duty be imposed upon an appropriate entity or agency to assess and ensure the adequate provision and co-ordination of SAR facilities on the Thames.
Unknown
8 — Keep Thames search and rescue under review
Recommendation: We welcome the agreement by the RNLI to provide lifeboat cover on the Thames 24 hours a day 365 days of the year and recommend that the SAR requirements on the Thames be kept under continuous review.
Unknown
COVID-M5.11 — Data and Technology in Emergency Procurement
Recommendation: Within three years of the publication of this Report, the systems for the procurement and distribution of healthcare equipment should be digitalised and interoperable across the UK government and devolved administrations. As a minimum, these systems should be able to …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
COVID-M5.9 — Commercial Framework for Emergency Procurement
Recommendation: The UK government and devolved administrations should collaborate to establish a UK-wide commercial framework agreement of pre-approved external specialists in the emergency procurement and distribution of healthcare equipment. The framework should be refreshed every three years.
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
COVID-M5.7 — Trade and Industry in the Civil Emergency Strategy
Recommendation: The UK-wide whole-system civil emergency strategy, which the Inquiry has recommended should be developed by the UK government and devolved administrations (see the Inquiry’s Module 1 Report, Recommendation 4), should include specific objectives for international trade and domestic industry during …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
Prevention of Future Deaths reports(160)— showing 50 strongest matches
Jessica Ashton-Pyatt
Concerns: The response to the patient's admission was uncoordinated and lacked consultant leadership. Additionally, the resuscitation room defibrillator was not charged, and no defibrillation pads were available.
Overdue
David Selman
Concerns: The coroner raises concerns about miscommunication between the control room and ambulance staff regarding instructions to 'stand down' versus 'stand back', and the lack of continual assessment of a patient's symptoms to ensure appropriate ambulance deployment.
Overdue
Janet Richardson
Concerns: The coroner noted concerns regarding the circumstances in which the deceased fell into the sea during a medical evacuation rescue.
Response (Newmarket Promotions Ltd): • The respondent's clients will ensure that the Coroner's recommendations are forwarded to their suppliers, including Cruise Maritime Services International Ltd (CMV). • The respondent's clients will request that their … (AI summary)
Response (Cruise Maritime Services International Limited): • The respondent stated its existing procedure is to follow the procedures set out by the appropriate rescue service during a rescue operation. • The respondent noted that the Norwegian … (AI summary)
Overdue
Andrew Phrydas
Concerns: London Underground lacked a process to simultaneously shut down intersecting lines and an effective method to alert train drivers to a person on the track.
Overdue
Dr Edward Slaney
Concerns: The coroner notes a lack of appropriate criteria for assessing the wind effects of tall buildings on highway users' safety. There is also a need for guidance to planning authorities to consider these wind effects on all road users.
Overdue
Umul Audu
Concerns: The coroner noted a lack of transport heater availability, which could lead to patients becoming hypothermic during transfer and potentially result in death.
Response (University College London Hospitals NHS Foundation Trust): • The Trust carried out a full investigation into the case. • The Trust stated it would not propose to introduce transport heaters, noting that current practice aligns with national … (AI summary)
Responded
Amy Friar
Concerns: The coroner notes that the lack of a universal emergency code system across the prison estate creates potential confusion and risks delaying assistance, particularly when staff transfer between prisons using different codes.
Overdue
Marco Lima De Araujo
Concerns: The coroner noted the absence of a formal protocol for reporting and coordinating rescue operations related to life-threatening incidents in Portsmouth Harbour.
Response (Maritime Coastguard Agency): • MRCC Solent and QHM are members of the SOLFIRE multi-agency response group. • These organisations participate in annual multi-agency exercises. (AI summary)
Responded
Janette Sutherland
Concerns: The presence of a drainage channel and concrete headwall represents a hazard to road users. A safety barrier should be erected to prevent vehicles leaving the carriageway and impacting the headwall.
Response (Caerphilly County Council): • Officers will investigate the site to provide recommendations and potential measures. • A survey of the site was conducted on 27 March 2014. • The Road Restraint Risk Assessment … (AI summary)
Response (Caerphilly County Council): • Caerphilly County Council undertook a topographic survey and a Road Restraint Risk Assessment Process (RRRAP) to evaluate the hazard. • The council decided to demolish the headwall and re-profile … (AI summary)
Responded
Christopher Williams
Concerns: The defibrillator machine was inoperable and had not been checked daily as required. There was no cross-check system or policy for the management of sudden unexpected deaths in place at the hospital.
Overdue
M5 (Seven)
Concerns: The coroner identified risks associated with greatly reduced visibility on the M5 motorway due to a nearby firework display, and the absence of automatic signalling to detect speed reductions and warn approaching drivers.
Overdue
Joan Richardson
Concerns: The coroner noted concerns regarding GP practices closing for staff training without a doctor available for emergencies during normal hours, and the impact of a significant delay in assessing an obviously unwell patient leading to delayed hospital referral.
Response (Leeds West Clinical Commissioning Group): • A joint letter will be sent to all practice managers and senior partners in Leeds, reminding them of their obligations and recommending improvements to patient communication regarding urgent care … (AI summary)
Overdue
Julie Robertson
Concerns: The absence of a blood fridge on the ward caused a delay in accessing anticipated blood. Additionally, poor record keeping was identified, with staff showing ongoing unawareness of good practice despite some training.
Overdue
Edna Smither
Concerns: The coroner noted insufficient staff First Aid training for responding to choking incidents and a lack of clear leadership during emergencies. There were also delays in reporting incidents under RIDDOR guidance.
Overdue
Rosalind Adshead
Concerns: Concerns were raised regarding the unsafe transfer of a severely ill patient between hospitals in the early hours of the morning, with the coroner noting that ambulance shortages during the day should not be a valid excuse for such timing.
Overdue
Sapper Dylan Gibson
Concerns: The coroner identified a lack of routinely available master keys at the guard room for buildings at Perham Down Barracks and other sites, which could hinder emergency access.
Response (Ministry of Defence): • 26 Engineer Regiment has implemented the recommendation and now holds keys to all buildings and rooms in the guardroom for emergency access. • The Ministry of Defence is updating … (AI summary)
Responded
Sandra Danks
Concerns: An interruption in the electricity supply stopped the main oxygen apparatus, and there was no backup system to ensure continuous oxygen provision.
Response (BOC Healthcare): • BOC Healthcare conducted a full review of its general policies and procedures for oxygen concentrator supply. • BOC Healthcare confirmed it supplied a back-up oxygen cylinder and provided training … (AI summary)
Overdue
Peter Mackie
Concerns: Concerns were raised regarding the insufficient number of first aiders available at Springhill site, particularly at night, and potential delays in healthcare staff moving between prison sites. There is also a lack of clear guidance for staff on when to commence CPR.
Response (HM Prison and Probation Service): • HMP Grendon and Springhill are working to increase the number of trained first aid staff, with a new risk assessment system for 24-hour cover to be operational within 12 … (AI summary)
Responded
Garry Gilbey
Concerns: The prison lacked a clear policy for calling an ambulance, relying on subjective staff judgment, and had inconsistent recording of healthcare events, hindering effective handover and review.
Response (Department of Health): • The Department of Health and NOMS issued guidance in 2011 regarding emergency access for ambulance services to prisons, which includes provisions for calling an ambulance in life-threatening situations. • … (AI summary)
Response (HM Prison and Probation Service): • HM Prison and Probation Service issued Prison Service Instruction 2013/03 Emergency Response Codes, which provides guidance on calling medical emergencies and requires governors to have a local protocol. • … (AI summary)
Responded
Noreen Porter
Concerns: Care home staff did not perform CPR when the deceased collapsed, and there was no process or procedure in place to ensure resuscitation during an emergency.
Response (Bupa): • Focussed supervisions were carried out with all nursing staff to cover Bupa's policy on CPR and the circumstances in which it must be commenced. • Bupa's policies on resuscitation … (AI summary)
Responded
Lana-Liza Chervonenko
Concerns: Insufficient medical cover and high activity on the labour ward led to delays in patient review, documentation errors, and communication gaps between clinical teams. The coroner also noted no system existed for theatre staff to proactively notify treating teams of theatre availability.
Overdue
Andrea Thirkell
Concerns: The coroner identified a lack of structured monitoring for patients experiencing discharge delays and an absence of a formal trust policy or guidance for late-night discharges, which could lead to inconsistent decisions.
Overdue
Davina Tavener
Concerns: The coroner noted that current aviation safety regulations do not mandate all aircraft to carry essential medical equipment, including defibrillators, airway adjuncts, and suction equipment, which medical experts deem critical for passenger survival during a cardiac arrest.
Response (IAA): • The Irish Aviation Authority (IAA) provided a summary of current automated external defibrillator (AED) carriage by Irish Air Operator Certificate holders. • The IAA Chief Executive wrote to Ryanair … (AI summary)
Response (EASA): • EASA stated it would engage with its Member States to reconsider the situation regarding mandated medical equipment on aircraft through analysis of available data. • EASA confirmed it would … (AI summary)
Response (CAA): • The CAA stated it would keep evidence of such incidents under review and share information and data with EASA colleagues. • The CAA indicated it would further examine the … (AI summary)
Responded
Kenneth Bailey
Concerns: The coroner noted concerns regarding the limited operating hours of the local fire station, which resulted in a delay in fire service arrival and prompted unqualified individuals to attempt a rescue, placing themselves at risk.
Response (Greater Manchester Fire and Rescue Service): • Greater Manchester Fire and Rescue Service approved a revised duty system for Mossley Fire Station on 23 July 2015, based on 12 wholetime staff providing 24-hour cover. • A … (AI summary)
Responded
Stanley Oliver
Concerns: The coroner noted the absence of an out-of-hours on-call rota for GI Radiologists to perform urgent procedures like percutaneous cholecystostomy, identifying this as a national issue that poses a risk to patient management.
Response (S Oliver): • The Trust updated a Standard Operating Procedure to incorporate support from Central Manchester NHS Foundation Trust for weekend non-vascular intervention services. • The Trust committed to developing a non-vascular … (AI summary)
Response (Department of Health): • NHS England has been working with the British Society for Interventional Radiology to improve access to interventional radiology across England. • Clinical standards for seven-day services were developed, including … (AI summary)
Responded
Thelma Jones
Concerns: The report identifies recurring issues related to the Acute Medical Unit (AMU), specifically regarding the care provided to patients admitted with acute illness.
Response (Brighton and Sussex University Hospitals NHS Trust): • The Trust carried out a careful review of the medical records with appropriate personnel. • The Trust stated it did not believe remedial action was necessary regarding the identified … (AI summary)
Responded
Dennis Stark
Concerns: The coroner noted that the absence of a lift at Newton House significantly delayed the emergency medical evacuation of an unresponsive resident from the second floor. This raises concerns about the safe removal of future residents requiring urgent medical attention, especially those with physical limitations.
Overdue
Christine McNamara
Concerns: The coroner identified a lack of pathways for post-ERCP patients with complications and issues with out-of-hours radiography referral, noting no surgical consultant was on call from Maidstone during the working week.
Response (Maidstone and Tunbridge Wells NHS Trust): • A new pathway for suspected post-endoscopy complications was devised and implemented in January 2016, with a review scheduled for October 2016 to assess its clarity. • The Trust stated … (AI summary)
Responded
Jasmine Lapsley
Concerns: The coroner identified a lack of reliable air support in North West Wales during night hours and an ineffective rota, communication, and recruitment process for Community First Responders. Concerns were also raised about the Welsh Ambulance Service Trust not increasing resources for seasonal population increases.
Response (Welsh Government): • The Welsh Air Ambulance is expanding its fleet, with an additional helicopter in July 2016 and funding secured for three more in early 2017. • A pilot of hand-held … (AI summary)
Responded
Arthur Mason
Concerns: The coroner noted a lack of risk assessment training for senior staff, who relied on their experience over Health & Safety Executive documentation. Concerns were also raised about staff not fully recognising task-related risks and the absence of a comprehensive emergency plan on the farm.
Response (Maurice Mason Ltd): • The company has implemented a new work method for grain bins, prohibiting personnel entry, thereby eradicating associated risks. • Maurice Mason Ltd has contracted an external safety management company … (AI summary)
Responded
Ronald Hamer
Concerns: The coroner noted an ambulance response time of nearly 2 hours and 40 minutes for an Amber 2 call, significantly exceeding the 20-minute target. Concerns were raised about the lack of communication with the patient's family and insufficient planning for maintaining services during periods of high call volume.
Response (Welsh Ambulance Service NHS Trust): • The Trust developed an Action Plan in response to the Regulation 28 report. • Actions for improvement are being monitored by a Task and Finish Group and scrutinised by … (AI summary)
Overdue
John Crittall
Concerns: The coroner identified an acutely unwell patient was admitted to a private hospital without HDU/ITU facilities or staff trained for critical care. Concerns were also raised regarding the chest drain insertion's non-adherence to best practice, lack of real-time ultrasound guidance, and insufficient post-procedure checks.
Response (Royal College of Radiologists): • The Royal College of Radiologists stated it would make its Fellows and members aware of the British Thoracic Society Pleural Disease Guideline 2010. (AI summary)
Response (Mount Alvernia Hospital): • The hospital updated its protocol for the care of patients with a chest drain and strengthened processes for managing pleural infection, aligning with British Thoracic Society guidelines. • The … (AI summary)
Responded
Christopher Sears
Concerns: The coroner identified a lack of requirements for bus drivers transporting students to have Basic Life Support training or established emergency protocols. Concerns were also raised that Basic Life Support training is not part of the national curriculum for secondary education.
Response (Department for Transport): • The Department for Transport asked the Driver and Vehicle Standards Agency (DVSA) to undertake promotional activity to raise awareness of the relevance of basic life support training for bus … (AI summary)
Response (Department for Education): • The Department for Education (DfE) stated its intention that local authorities ensure school bus drivers and escorts receive training in basic life support skills and emergency protocols. • The … (AI summary)
Responded
Miles Abel
Concerns: Concerns were raised regarding the GP referral procedure to the Community Mental Health Team, specifically the lack of an audit trail for faxed requests and inconsistent follow-up calls to confirm receipt. This meant the CMHT might be unaware of patient referrals.
Response (The Endless Street Doctors Surgery): • The surgery has instituted a new Standard Operating Procedure for urgent fax referrals. • A fax log documentation system has been implemented to record who sent faxes, and the … (AI summary)
Response (Department of Health): • The Department of Health noted that Endless Street Surgery had implemented a strengthened system for referring patients to the Community Mental Health Team. (AI summary)
Responded
Imad Hassan
Concerns: The coroner identified a lack of a formal backup plan for patients requiring PCI when primary hospitals cannot accept them, and no agreed pathway for unconscious STEMI patients needing tertiary services. This absence of capacity and clear pathways increases the risk of death.
Response (Hassan): • Cwm Taf University Health Board worked with WHSSC and provider units to develop an interim solution for PCI procedures. • An agreed interim position between the respective organisations was … (AI summary)
Response (Imad Hassan): • United Hospitals University Bristol Trust has confirmed it will accept patients in the event of insufficient critical care capacity in South Wales. • The usual regional PPCI centre will … (AI summary)
Overdue
Jane Reason
Concerns: There is a need for more public access defibrillators, particularly in colleges and schools, and further consideration is required regarding their placement and public education on their use.
Response (Resuscitation Council UK): • The Resuscitation Council UK organised the 'European Restart a Heart' event, which trained over 150,000 children and young people in basic life support. • The organisation published 'A to … (AI summary)
Response (Department for Education): • The department published a guide on automated external defibrillators in April 2016. • New guidance relevant to further education colleges has been published. • The department will write to … (AI summary)
Response (NHS England): • The Treasury allocated £2m for public access defibrillators, with £1m already distributed. • The remaining £1m for public access defibrillators is expected to be available within 3-6 months. • … (AI summary)
Response (British Heart Foundation): • The British Heart Foundation (BHF) provides free CPR training kits to secondary schools and community groups through its Call Push Rescue programme. • The BHF provides part funding for … (AI summary)
Responded
Barbara Turner
Concerns: The coroner noted that the resuscitation team call-out criteria in the Trust's policy are too broad, potentially delaying intervention for critically ill patients. Concerns were also raised about the unsafe method of patient transfer to and from the CT scanner, which lacked appropriate medical escort and equipment.
Overdue
James Fox
Concerns: Concerns were raised regarding the accuracy of close-range firearm use, the lack of less lethal firearms or ballistic shields, and insufficient contingency planning. The coroner also noted inconsistencies in police training curricula and the absence of national standard training.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) maintains national standards for armed officers' weapon handling and shooting accuracy. • The MPS regularly reviews these standards to ensure officers are trained to … (AI summary)
Responded
Christopher Brennan
Concerns: The coroner identified a lack of specific policy for managing self-harm risks from items in an adolescent psychiatric unit, which led to inconsistency. Concerns also included the absence of a laryngoscope in the unit's emergency equipment, an item previously used successfully.
Overdue
Liam Day
Concerns: The coroner noted a lack of preparedness for cold water, including inadequate safety equipment and no means of requesting help. The report highlights the serious risks posed by dangerously low sea temperatures and the rapid onset of hypothermia for those unaware.
Response (BMC): • The BMC will make climbers aware of the risks of cold water shock in its guidance and raise this with guidebook writers. • The BMC will update its advice … (AI summary)
Responded
Margaret Wakefield
Concerns: The coroner noted a lack of timely haemofiltration for a patient with chronic renal disease following a high-risk heart procedure. This potentially life-saving treatment was not available, leading to further deterioration and death, and concerns were raised regarding the need for improved access and contingency planning.
Response (Royal Cornwall Hospital NHS trust): • The funded establishment for registered nurses in the Critical Care Unit was increased, with recruitment for new posts underway. • A new system was introduced for the Critical Care … (AI summary)
Responded
Sandra Brotherton
Concerns: The coroner identified a lack of contingency planning for sole carers and inadequate documentation for sharing care plans with personal assistants. Concerns included difficulties securing urgent psychiatric appointments and no follow-up after a carer reported an unusual incident.
Response (Pennine Care NHS Trust): • The Trust's Care Programme Approach Policy was updated in November 2016, and the Trust records audit was reviewed, amended, and went live in January 2017 to address contingency planning … (AI summary)
Responded
Peter Keep
Concerns: The coroner noted an inappropriate use of sedation and a lack of a sedation policy for cardiac electrophysiological procedures, with an inconsistent approach in the catheter lab. There were also gaps in staff training on anxiolytics and analgesics, and insufficient action plans for patient complications.
Response (Frimley Health NHS Trust): • The Trust relaunched the Safe Sedation Committee. • The Committee is reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults. • The Cardiology team discussed the … (AI summary)
Responded
Terence Millington
Concerns: The coroner identified issues with an on-call senior doctor's arrangements for being contacted by telephone, the next on-call consultant's prompt attendance due to distance, and the incorrect fulfilment of a request for two packs.
Response (Sheffield Teaching Hospital NHS Trust): • The Trust's consultant discussed the incident with the senior doctor, and local induction for ENT staff now includes guidance on remaining contactable, with plans to incorporate this into the … (AI summary)
Responded
Grant Richards
Concerns: The coroner noted the GP surgery's failure to action a recommended chest clinic follow-up from an A&E discharge summary, alongside a lack of contingency systems and poor attention to documents, including faxes from mental health agencies.
Overdue
Michael Brennan
Concerns: The coroner noted that a patient transfer backup plan relied on a bed that was unavailable, raising concerns that clinicians lacked real-time bed status information across the Trust's multiple sites when devising the plan.
Response (University College Hospitals NHS Trust): • The Trust stated it would amend its bed management policy by the end of May 2017 to include twice-daily updates on Westmoreland Street Hospital bed states. • The Trust … (AI summary)
Responded
Patrick Woods
Concerns: The coroner noted that the hospital's equipment portfolio was unknown, which prevented the identification of potentially dangerous equipment, subsequent risk assessment, and actions to prevent future harm to patients.
Response (Draeger Medical UK Limited): • Draeger updated its training documentation, including the Basic Skills Checklist, Workbook, Quick Guide, Practical Exercises, PowerPoint presentation, and Training Needs Analysis, to enhance clinician competence regarding machine functionality and … (AI summary)
Response (Luton Dunstable University Hospital): • The Trust stated it maintains an electronic database of all equipment, including location, service history, and risk categorization. • The Trust confirmed that incidents involving equipment are reviewed by … (AI summary)
Responded
Andrew Wilson
Concerns: The coroner noted the absence of peritoneal dialysis arrangements at Maidstone Hospital, including a lack of trained staff, equipment, and a system for transporting equipment from patients' homes, compounded by clinicians' unawareness of these limitations.
Overdue
Sousse (Tunisia)
Concerns: Concerns were raised that other travel companies may lack security advisors at board level and may not prominently display links to the Government's Travel Aware programme, potentially impacting hotel security and public awareness of terrorist risks.
Overdue
William Wilson
Concerns: The coroner noted the designated first aider was not called to the scene, and the system for alerting them was unclear. Staff attending to the deceased also lacked familiarity with all life-saving first aid techniques.
Overdue
Select committee recommendations(825)— showing 50 strongest matches
#48 —
Recommendation: With greater and greater private ownership of public risk, there has never been a greater public interest in ensuring that private firms are able to prepare for disruption and recover quickly when it occurs. Risk is inevitable in private enterprise, …
#40 —
Recommendation: We recommend that the Government’s forthcoming Critical Minerals Strategy: • Sets specific targets for domestic production, recycling and processing. • Clearly sets out the UK’s approach to diversifying these supply chains through bilateral agreements with allies. • Designates ‘Critical Mineral …
#39 —
Recommendation: The Government’s attempts to diversify supply chains, and to safeguard sources of critical minerals, will not be successful unless there is a long- term plan for the UK’s supply chain. The forthcoming Critical Minerals Strategy is an opportunity to accelerate …
#38 —
Recommendation: The Government should conduct a regular prioritisation exercise with industry and Parliament to identify the UK’s critical supply chains. This assessment should combine data regarding critical raw material needs, and possible supply chain disruptions or dependencies, across the economy. From …
#32 —
Recommendation: We recommend that the creation of a cross-Government technology forecasting unit. This would lead an annual technology forecasting process, to support a co-ordinated response to technological change and the risk of new harms across the UK’s economic security toolkit. This …
#21 —
Recommendation: The Government should conduct annual cross public sector-private sector exercises to specifically test the response to events in which multiple economic security risks manifest simultaneously. One example would be the scenario set out in the Strategic Defence Review: efforts to …
#20 —
Recommendation: We have heard through this inquiry that there is currently no shared space for industry and Government to simulate their response to combined attacks across multiple sectors, or to plan public and private investments that improve long-term resilience. This is …
#19 —
Recommendation: The ten key threats we outline above will rarely, if ever, present in isolation. Hostile actors are expected to target the UK economy along multiple vectors simultaneously. This poses particular challenges for an economy characterised by the private ownership of …
#13 —
Recommendation: Over the coming years, emerging technologies and the net zero transition will increase global demand for critical minerals exponentially. The absence of any significant domestic presence in the mineral value chain leaves the UK significantly exposed to disruptions in their …
#11 —
Recommendation: The world has never been more interconnected, and the UK economy is dependent on complex and interwoven supply chains. Consumers, businesses and public institutions rely on supply chains where objects repeatedly cross borders, often on a “just-in-time” basis where the …
#10 —
Recommendation: Threats to the UK from state actors that fall short of military action are continuing to grow. Foreign powers are increasingly willing to coerce or undermine others using economic tools or by exploiting economic interdependencies. Russia, China, Iran and North …
#8 —
Recommendation: The UK faces increasingly complex transnational threats. The devastating impacts of the Covid-19 pandemic and the rapidly changing climate are two examples of existential challenges, against which the UK economy must become more resilient. (Conclusion, Paragraph 35)
#1 —
Recommendation: Economic security is fundamental to national security. We welcome the Government’s recognition of this. By its very nature however, only industry and Government working jointly and severally together can safeguard the UK’s economic security through the ‘whole of society approach’ …
#54 —
Recommendation: The Government must ensure that utility providers are involved in the production of a holistic national resilience framework plan as early and fully as possible to safeguard the future of energy and water for megaprojects.
#28 —
Recommendation: Supply chains for new towns can be made more resilient to a changing climate and global economic shocks by using a diverse range of building materials, ideally sourced from the UK. National leadership
#26 —
Recommendation: An international supply chain is more affected by global shocks, potentially risking the successful delivery of domestic programmes such as new towns. 41 Prioritising the use of domestic materials and products could, therefore, safeguard national supply chains and expose them …
#8 —
Recommendation: The Government must ensure that utility providers are involved in the production of a holistic national resilience framework plan as early and fully as possible to safeguard the future of energy and water for megaprojects.
#3 —
Recommendation: Supply chains for new towns can be made more resilient to a changing climate and global economic shocks by using a diverse range of building materials, ideally sourced from the UK.
#22 —
Recommendation: The OfS has indicated that its role is not to bail out failing providers but to support their students to continue their studies in other institutions. While this was successful in the case of a recent market exit by a …
Response attribution not verified
#27 —
Recommendation: Chief Pharmacists must have the powers and resources to ensure high quality homecare medicines services in their area. This should include powers and responsibility to develop and support alternative ‘back up’ provision to deliver homecare medicines services, such as through …
Response attribution not verified
#184 —
Recommendation: As with other economic activity in the Arctic, the growth of fishing is currently constrained by ice coverage and the challenges of operating in a harsh environment with limited search and rescue facilities. Commercial fishing is concentrated in the Bering …
Response attribution not verified
#172 —
Recommendation: We heard that, like the Arctic Seven, India is concerned about Russia’s deepening relationship with China, including in the Arctic and it has an interest in preventing a strong Sino-Russian partnership. 198 Captain Bisen explained: “The Arctic presents India with …
Response attribution not verified
#163 —
Recommendation: It is essential that the UK Government pays close attention to Sino -Russian collaboration in the Arctic. UK scenario planning should consider the possibility that China could in the future seek to establish a military presence in the Arctic. This …
Response attribution not verified
#96 —
Recommendation: Finland and Sweden’s accession to NATO provides an opportunity for the UK to deepen its already extensive defence co-operation with the Nordic states. The RAND Corporation suggested this could include deepening co-operation around common platforms, such as the F-35 combat …
Response attribution not verified
#84 —
Recommendation: Maritime sabotage is difficult to deter. The rules of engagement in peacetime constrain the response to ships suspected of engaging in maritime sabotage. 99 Moreover, states may be unable or unwilling to publicly attribute attacks to adversaries because the maritime …
Response attribution not verified
#74 —
Recommendation: Dr Pincus told us that alongside conventional deterrence, NATO also has a role in developing a strategy for responding to sub-threshold threats: “We should have consultations and draw up contingency plans for hybrid or grey-zone activities in the Arctic, how …
Response attribution not verified
#73 —
Recommendation: Russia has maintained a strategic foothold on the archipelago, operating a consulate and a coal mine in the settlement of Barentsburg. We heard that Norwegian policymakers believe they have established and well-resourced mechanisms to manage incidents on Svalbard. 83 Prof …
Response attribution not verified
#71 —
Recommendation: Minna Ålander of the Finnish Institute for International Affairs told us that Russian jamming of GPS signals in the Gulf of Finland presents a serious issue for civilian air traffic in the region. 80 Lieutenant Commander John Ash noted that …
Response attribution not verified
#70 —
Recommendation: The Norwegian Aviation Authority reported in mid-2022 that Russian GPS jamming had intensified following Russia’s full-scale invasion of Ukraine. 77 Russian military jets also compromise air traffic safety by frequently flying with their transponders switched off. 78 In October 2022, …
Response attribution not verified
#69 —
Recommendation: The UK’s Nordic allies are at the front line of Russian sub-threshold operations. Russia regularly engages in a range of disruptive actions to test the Nordic states’ responses and resilience. This includes GPS jamming, military exercises simulating attacks on its …
Response attribution not verified
#68 —
Recommendation: Several witnesses emphasised that one of the most significant areas of concern in the Arctic related to sub-threshold activity—malign activity conducted by an adversary below the level required to trigger a military response. Dr Pincus told the Committee that these …
Response attribution not verified
#66 —
Recommendation: Despite tensions between Russia and the West, some forms of co-operation with Russia have been retained. For example, the Norwegian Joint Headquarters in Reitan has maintained a hotline with the Admiral of the Northern Fleet, which acts as an important …
Response attribution not verified
#62 —
Recommendation: Dr Pincus noted that unintentional escalation could arise from bad weather, an accident, or an unintended incident, adding that: “The Arctic is a harsh place to operate in the best of circumstances. Russian operators have been known to conduct unsafe …
Response attribution not verified
#61 —
Recommendation: Growing maritime activity in the Arctic and the deterioration of relations between Russia and the West have increased the risk of accidental escalation in the Arctic.
Response attribution not verified
#60 —
Recommendation: The consensus view from our witnesses was that the two principal threats emerging from within the Arctic are: (1) escalation arising from accidents, miscalculation, or human error; and (2) malign activity in the ‘grey zone’ below the threshold for armed …
Response attribution not verified
#26 —
Recommendation: In the short-term, UK and EU demand for Norwegian oil and gas is likely to increase and will create pressures to raise production, including in the Arctic offshore. This will carry with it greater environmental and safety risks.
Response attribution not verified
#25 —
Recommendation: Arctic shipping is concentrated in the European Arctic, in close proximity to the UK. As commercial and private shipping increases in the region, demands on the UK’s maritime search and rescue capabilities are likely to grow. The UK Government should …
Gov response: Partially agree. 24. The UK recognises the importance of close cooperation with the Arctic states and the Arctic Council in relation to search and rescue and disaster preparedness response. We participate in a range of …
Position Not Stated
#23 —
Recommendation: Commercial maritime activity in the Arctic is likely to grow significantly in the coming decades, increasing the risk of pollution and accidents.
Response attribution not verified
#17 —
Recommendation: It is essential that the UK Government pays close attention to Sino-Russian collaboration in the Arctic. UK scenario planning should consider the possibility that China could in the future seek to establish a military presence in the Arctic. This would …
Gov response: Agree. 13. The UK is monitoring closely Sino-Russian collaboration in the Arctic, especially around strengthened maritime security cooperation and cooperation in the development of new shipping routes. We remain alert to the possibility of Chinese …
Position Not Stated
#7 —
Recommendation: The UK’s Arctic allies have continued to work with Russia in areas such as search and rescue and military-to-military communication for the purpose of deconfliction, emergency response, and reassurance. It is in the UK’s interest that these channels of communication …
Response attribution not verified
#6 —
Recommendation: The risk of unintentional escalation in the Arctic following an accident has risen as a result of increasing maritime activity in the region, and the sharp deterioration in relations between Russia and the West . The UK must continue to …
Response attribution not verified
#4 —
Recommendation: Russian sub-threshold activity in the High North is a significant and growing threat. The UK and its allies should prepare contingency plans to detect, deter and respond to hybrid and ‘grey-zone activities’, and consult on how to best do this …
Response attribution not verified
#3 —
Recommendation: While it is not in Russia’s interest to start a conventional conflict in the Arctic, sub-threshold activity and accidental escalation represent significant risks to the region’s security.
Response attribution not verified
#2 —
Recommendation: The Arctic will remain central to Russia’s military and strategic thinking. The military setbacks it has suffered in Ukraine, and Finland and Sweden’s NATO accession, will only increase the importance of the region for Russia’s leadership. Russia has a legitimate …
Response attribution not verified
#8 —
Recommendation: Preventing and reducing waste at all stages in the food chain should be a central component of the Government’s food strategy, as this is a quick-win compared to other actions to maintain food security in the face of environmental change. …
Response attribution not verified
#6 —
Recommendation: Defra collaborates with other Government departments and with industry on food security issues, but this work is neither sufficiently co-ordinated nor long-term. The Government should establish a cross-government, cross-sector food security body to bring together all the actors in the …
Response attribution not verified
#5 —
Recommendation: Given the increasing volatility in food supplies, not just due to extreme weather, but also due to the recent geopolitical and health crises we have experienced, the Government should publish its food security report annually rather than every three years …
Response attribution not verified
#4 —
Recommendation: The food system globally and in the UK has become too concentrated and too driven by price alone. The Government and food industries must focus on embedding more diversity of produce and farming methods within the food system and reducing …
Response attribution not verified
#1 —
Recommendation: Food self-sufficiency is an important aspect of food security. When developing relevant strategies, the Government must recognise the risks of national over- reliance on imports for many products, as experience earlier this year of empty shelves for certain salad items …
Response attribution not verified
#27 —
Recommendation: There is a high risk that the Government will face a catastrophic ransomware attack at any moment, and that its planning will be found lacking. In 2020, this Committee examined the Government’s preparations for the Covid-19 pandemic, considering what it …
Response attribution not verified
HSSIB safety recommendations(32)
Potential under-recognised risk of harm from the use of propranolol
National resuscitation guidance may benefit from further specific information concerning the additional challenges and treatment options available for other types of medication overdose.
Safety Observation
Electronic patient record (EPR) systems – thematic review
Does your organisation have contingency plans and processes to maintain patient safety when there are EPR system problems, and are they shared with staff?
Learning Prompt
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that the Association of Ambulance Chief Executives, in collaboration with HM Prison and Probation Service, sets up formal communication routes, at both national and regional levels, between prison and ambulance services to escalate concerns, review risks and improve …
Safety Recommendation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service reviews and implements changes to current communication methods between staff at the scene of an incident and the ambulance service call centre. This is to ensure that situational information about the patient …
Safety Recommendation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Association of Ambulance Chief Executives, reviews and amends the design of the medical emergency response card, to better support staff in identifying emergency situations and providing the situational …
Safety Recommendation
Medication not given: administration of time critical medication in the emergency department
How does your organisation support staff to work safely when ePMA systems may not be functioning to ensure time critical medications are not missed?
Learning Prompt
Safety issues for people experiencing a mental health crisis who come into contact with urgent …
HSSIB recommends that the Department of Health and Social Care urgently reviews the current legal framework and addresses the current legislative gaps in emergency care for people in mental health crisis and clarify the extension of legal powers for health …
Safety Recommendation
Electronic patient record systems – risk from loss of functionality
Monitor for and respond to loss of functionality events.
Investigation Scope
Electronic patient record systems – risk from loss of functionality
Prepare for a loss of functionality as part of their business continuity.
Investigation Scope
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the Association of Ambulance Chief Executives works with the National Poisons Information Service to review its guidance on the treatment and transportation of patients known to have taken an overdose of propranolol or other beta blocker …
Safety Recommendation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to have greater consistency in the provision of FFP3 respirator masks to assist in their response to COVID-19.
Safety Observation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHS England and NHS Improvement: supports additional capacity for testing for NHS patients and staff (Pillar 1 testing) facilitates the accessibility of rapid testing for NHS trusts, as soon as an increase in rapid testing supplies …
Safety Recommendation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that the Department of Health and Social Care reviews and identifies the mechanisms which enabled regional and local organisations to adapt and respond with agility during the pandemic. This should inform the development of a strategic approach …
Safety Recommendation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
donning PPE prior to an ambulance crew entering a woman’s home, adding time before resuscitation could commence.
Learning Prompt
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
It may be beneficial for strategic stakeholders in the healthcare system to understand and articulate adjustments in risk tolerance and thresholds in critical situations. During the investigation, HSIB became aware of changes the UK Health Security Agency made to processes …
Safety Observation
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
HSIB recommends that NHS England reviews the risks associated with increased use of telephone triage in response to national healthcare emergencies. Consideration should be given to applying any recommendations of this review across telephone triage services within the wider healthcare …
Safety Recommendation
Patient care in temporary care environments
Has your organisation made adaptations to temporary care environment spaces that include having essential equipment nearby? For example, emergency call bells, communication systems, personal call bells, spaces for personal care and invasive treatments.
Learning Prompt
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service enhances the existing training delivered to prison officers, to increase their ability to identify medical emergencies that require 999 calls to be made by prisons, thereby reducing the number of calls and …
Safety Recommendation
Electronic patient record systems – risk from loss of functionality
Ensure staff are aware of and prepared to respond to periods of loss of functionality.
Investigation Scope
Potential under-recognised risk of harm from the use of propranolol
It is recommended that NHS England/NHS Improvement evaluates current approaches to the clinical oversight of overdose calls within ambulance control rooms and leads on work to develop a national framework to describe the requirements for appropriate clinical oversight of overdose …
Safety Recommendation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
delays due to the additional infection prevention control requirements, including donning and doffing PPE multiple times as a clinician moved between areas to obtain test results from equipment located on another ward during resuscitation
Learning Prompt
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
commencing urgent (category 1) caesarean section was delayed while staff donned PPE
Learning Prompt
Emergency response to heart attack
It may be beneficial if current guidance on the use of thrombolysis as an alternative to primary percutaneous coronary intervention in England is reviewed to consider the challenges posed in safely administering thrombolysis in the pre-hospital setting.
Safety Observation
Emergency response to heart attack
HSIB recommends that NHS England and NHS Improvement support the Joint Ambulance Improvement Programme to respond to emerging risks and research highlighting factors impacting on effective ambulance response.
Safety Recommendation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
HSIB recommends that NHS England and NHS Improvement develop a framework to support Trusts to anticipate operational risk in maternity services when delivering neonatal resuscitation.
Safety Recommendation
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
The UK Health Security Agency has taken steps to review contractual arrangements to ensure flexibility and the opportunity to implement the most appropriate contract for future public health issue.
Safety Action
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
The UK Health Security Agency has taken steps to assure itself of the safe and effective delivery of telephone triage for future healthcare emergencies. These have been tested through the delivery of services for Monkey Pox and Avian Flu.
Safety Action
Potential under-recognised risk of harm from the use of propranolol
Safety action by NHS England/NHS Improvement In March 2019, NHS England wrote to ambulance trusts in England regarding the management of cases where patients have self-harmed and are at risk of suicide. This included specific reference to patients who may …
Safety Action
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Neonatal resuscitation The review highlighted gaps between how neonatal resuscitation (delivery of inflation breaths with or without chest compressions) is expected or imagined to work and how it actually happens. This issue has been highlighted in other types of national …
Learning Prompt
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the Acute Trust, in collaboration with the Ambulance Trust, develops and implements a formal emergency department booking-in policy.
Safety Recommendation
Advanced airway management in patients with a known complex disease
HSSIB recommends that the Royal College of Anaesthetists works with the Association of Anaesthetists and relevant key stakeholders to implement critical incident training for all anaesthetists and anaesthetic assistants. This should include consideration of scenario-based training and include the principles …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have processes for identifying and prioritising safety and time-critical actions requested by secondary care?
Learning Prompt
NCEPOD recommendations(10)
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
CQC inspection actions(172)— showing 50 strongest matches
William Harvey Hospital
The trust must ensure there are clear arrangements for patients in the SCBU if the environment becomes unsuitable due to uncontrolled temperatures.
Must Do
William Harvey Hospital
The trust must ensure suitable alternative arrangements for the delivery of SCBU services are documented in the child health risk register if the environment becomes unsuitable.
Must Do
West Suffolk Hospital
The service must ensure they complete emergency drills in a baby abduction scenario.
Must Do
Westmorland General Hospital
The service must ensure all equipment is properly maintained and that staff do not use equipment that is not safe nor used for its intended purpose. Specifically, they should not use a domestic bath to support water birth. All staff …
Must Do
Westmorland General Hospital
The service must ensure staff assess and mitigate the risks to women’s health and safety in an emergency situation either during home birth or at the unit. They must ensure appropriate escalation and transfer takes place.
Must Do
Westmorland General Hospital
The department must ensure that the corridor escalation plan is adhered to and that incidents are appropriately recorded when the plan dictates.
Must Do
University Hospital of Hartlepool
The service should recommence simulation of child abduction to ensure their emergency preparedness.
Should Do
University Hospital of Hartlepool
The service should work with other trust services to implement baby abduction training.
Should Do
The York Hospital
The service should ensure resuscitation trollies are checked in line with trust policy and records are available to evidence completion.
Should Do
The York Hospital
The trust must review processes for ED staff completing full resuscitation trolley checklists to ensure all specialist live-saving equipment is stocked and in date in the event of an emergency.
Must Do
The York Hospital
The service must review processes for ED staff completing full resuscitation trolley checklists to ensure all specialist live-saving equipment is stocked and in date in the event of an emergency.
Must Do
The Tunbridge Wells Hospital at Pembury
The service should ensure staff complete abduction drills and are confident in the process to follow.
Should Do
The Tunbridge Wells Hospital at Pembury
The service must ensure that staff have carried out daily safety checks of emergency and specialist equipment.
Must Do
The Ipswich Hospital
The service must carry out and record regular baby abduction drills and evacuation drills.
Must Do
St Mary's Hospital
The trust should ensure that action to reassess concerns identified in baby abduction drills are carried out in a timely way.
Should Do
St Austell Hospital - Penrice Birthing Unit
The service should ensure staff complete regular birth pool evacuation training and baby abduction drills at Penrice Birthing Centre.
Should Do
Scarborough Hospital
The service must review processes for ED staff completing full resuscitation trolley checklists to ensure all specialist live-saving equipment is stocked and in date in the event of an emergency.
Must Do
Russells Hall Hospital
Managers should ensure that services are planned to meet the needs of local people with regard to the resuscitation area.
Should Do
Royal Cornwall Hospital
The serviceshouldensurestaffareawareofthebabyabductionpolicy,thepolicyisstrengthenedtoincludepreventativemeasures,andthatstaffofalllevelsareinvolvedinlivesimulations.
Should Do
Royal Cornwall Hospital
The serviceshouldevaluatecurrenttrainingprovisionforemergencyevacuationofthebirthpoolandensurebirthpoolevacuationsimulationsarecarriedouttoensureallstaffareconfidentandproficienttocarryoutthisprocedureinanemergency.
Should Do
Rochdale Infirmary
The service must ensure that all emergency trolleys are sealed, with a record of checks to show they are ready for use.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure there are clear arrangements for patients in the SCBU if the environment becomes unsuitable due to uncontrolled temperatures.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure suitable alternative arrangements for the delivery of SCBU services are documented in the child health risk register if the environment becomes unsuitable.
Must Do
North Devon District Hospital
The service should ensure the security of the unit is reviewed in line with national guidance. In particular staff’s ability to respond to a baby abduction.
Should Do
Mount Vernon Cancer Centre
The trust should ensure all emergency equipment is checked daily and documented.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that action cards are available to provide guidance to staff in the event of a major incident and staff receive appropriate training.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatthereisaresuscitationtrolleyavailabletostaffincaseofemergency.Regulation15(1)(f)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatdailychecksofemergencyboxesforhypoglycaemia,cordprolapse,sepsisandpre-eclampsiatakeplaceaspolicy.Regulation12(1)(2)(g)
Must Do
Liverpool Women's Hospital
The trust should consider reviewing the systems and processes used for checks of emergency equipment.
Should Do
Liverpool Women's Hospital
The trust should ensure that staff respond appropriately to activated baby alarms.
Should Do
Leighton Hospital
The service must ensure it implements a standard operating procedure for timely second emergency theatre provision at all times so that staff follow a reliable and standardised process to ensure compliance with the emergency caesarean response times to ensure women …
Must Do
George Eliot NHS Hospital
The service should ensure daily checks are completed and recorded for the resuscitaire on Drayton Ward.
Should Do
Fleetwood Hospital
The trust should consider a review of its current provision of lone working devices so that all community staff have access as required.
Should Do
Ellesmere Port Hospital
The trust should ensure resuscitation equipment is checked in line with trust policy.
Should Do
Edgware Community Hospital
The service should ensure appropriate checks and oversight was maintained on safety and specialist equipment including resuscitaire and resuscitation trolley.
Should Do
Doncaster Royal Infirmary
The trust should consider storing the resuscitaire which is currently stored in the bereavement room in another cupboard outside of this room.
Should Do
Doncaster Royal Infirmary
The trust should ensure that all resuscitation checklists include the name of the location and type of equipment named.
Should Do
Doncaster Royal Infirmary
The trust must ensure that there is a resuscitation trolley available to staff in case of emergency.
Must Do
Doncaster Royal Infirmary
The trust must ensure that all staff know the emergency procedures that are in place for patients who may deteriorate.
Must Do
Doncaster Royal Infirmary
The trust must ensure that there is out of hours senior support in place for community midwives and community staff are suitably trained for home birth emergencies.
Must Do
Doncaster Royal Infirmary
The trust must ensure that the missing emergency medicine from each box is replaced.
Must Do
Doncaster Royal Infirmary
The trust must ensure that daily checks of emergency boxes for hypoglycaemia, cord prolapse, sepsis and pre-eclampsia take place as policy.
Must Do
Doncaster Royal Infirmary
The trust must ensure that community staff are suitably trained for home birth emergencies.
Must Do
Crowborough Birthing Centre
The service must ensure that staff complete mandatory evacuation of the pool skills and drills training.
Must Do
Chorley and South Ribble Hospital
The trust should consider locating paediatric emergency information where children would be treated.
Should Do
Chorley and South Ribble Hospital
The trust should consider including checks of the transfer bag with other daily checks.
Should Do
Blackpool Victoria Hospital
The trust should consider involving all staff in baby abduction drills as per the providers policy.
Should Do
Airedale General Hospital
The service should enable timely access to evacuation nets for the birthing pools and this is monitored.
Should Do
The Walton Centre
The service should consider reviewing the number and availability of resuscitation trolleys in order to comply with Resuscitation Council (UK) guidelines.
Should Do
St Benedict's Hospice
The service must risk assess for emergency equipment including emergency medication required on the ward for resuscitation in line with the patient group and current national guidance. Where risks are identified, the trust must ensure this is equipment is provided …
Must Do
HMICFRS recommendations(21)
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service’s mobilisation system, which records information and dispatches resources to emergency incidents, isn’t reliable and crashes during emergency 999 calls. This unnecessarily delays the mobilisation of resources, which results in the public receiving a slower response …
Recommendation
FRS 2018-19 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: Surrey FRS doesn’t have a robust and sustainable system to support its operational response model. Recommendation: The service should ensure it understands and actively manages the resources and capabilities available for deployment.
Recommendation
FRS 2018-19 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: Surrey FRS doesn’t have a robust and sustainable system to support its operational response model. Recommendation: The service should ensure it has appropriate resources (people and equipment) available to respond to risk in line with its integrated …
Recommendation
FRS 2023-25 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: The service needs to improve its mobilisation system. Some long-term issues with the service’s mobilisation system could cause unnecessary delays in the dispatch of resources to emergency incidents. This would result in the public receiving a slower …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: We have serious concerns as to whether Buckinghamshire FRS has the resources it needs to meet its foreseeable risk. As a result of the financial position the service finds itself in, it doesn’t have enough operational firefighters …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service’s mobilisation system, which records information and dispatches resources to emergency incidents, isn’t reliable and crashes during emergency 999 calls. This unnecessarily delays the mobilisation of resources, which results in the public receiving a slower response …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service’s mobilisation system, which records information and dispatches resources to emergency incidents, isn’t reliable and crashes during emergency 999 calls. This unnecessarily delays the mobilisation of resources, which results in the public receiving a slower response …
Recommendation
State of Fire and Rescue: National Recommendations
As soon as is practicable the Home Office, NFCC and LGA, in consultation with the Fire Standards Board and APCC, should establish a programme of work that will result in consistency in four priority areas: (1) identifying and determining risk …
Recommendation
FRS 2018-19 CoC Recommendations: Surrey Fire and Rescue Service
Cause of concern: Surrey FRS doesn’t have a robust and sustainable system to support its operational response model. Recommendation: The service should put in place a response plan based on a thorough assessment of risk to the community.
Recommendation
FRS 2023-25 CoC Recommendations: Shropshire Fire and Rescue Service
Cause of concern: The service doesn’t have adequate processes, controls or internal governance arrangements in place to manage strategic risks, performance and improvement plans. Recommendation: The service should develop an action plan to make sure there are appropriate strategic oversight …
Recommendation
FRS 2023-25 CoC Recommendations: Shropshire Fire and Rescue Service
Cause of concern: The service doesn’t have adequate processes, controls or internal governance arrangements in place to manage strategic risks, performance and improvement plans. Recommendation: The service should develop an action plan to make sure the corporate risk register is …
Recommendation
FRS 2018-19 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: We have serious concerns about Northamptonshire FRS’s ability to respond to incidents. The service consistently doesn’t have available its minimum number of fire engines. Senior managers are not routinely told when this happens. Recommendation: The service should …
Recommendation
FRS 2023-25 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: The service needs to improve its mobilisation system. Some long-term issues with the service’s mobilisation system could cause unnecessary delays in the dispatch of resources to emergency incidents. This would result in the public receiving a slower …
Recommendation
FRS 2023-25 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: The service needs to improve its mobilisation system. Some long-term issues with the service’s mobilisation system could cause unnecessary delays in the dispatch of resources to emergency incidents. This would result in the public receiving a slower …
Recommendation
FRS 2018-19 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: We have serious concerns as to whether Buckinghamshire FRS has the resources it needs to meet its foreseeable risk. As a result of the financial position the service finds itself in, it doesn’t have enough operational firefighters …
Recommendation
State of Fire and Rescue: National Recommendations
The Home Office should consider the case for legislating to give chief fire officers operational independence. In the meantime, it should issue clear guidance, possibly through an amendment to the Fire and Rescue National Framework for England, on the demarcation …
Recommendation
State of Fire and Rescue: National Recommendations
The Home Office, in consultation with the fire and rescue sector, should review and with precision determine the roles of: (a) fire and rescue services; and (b) those who work in them.
Recommendation
State of Fire and Rescue: National Recommendations
As part of the next Spending Review, the Home Office in consultation with the Fire and Rescue Sector should address the deficit in the fire sector's national capacity and capability to support change.
Recommendation
ICIBI immigration recommendations(4)
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should develop robust contingency plans to prepare for future crisis events. These plans must focus on the accurate collection and assurance of data.
An inspection of Border Force operations at south coast seaports
Resolve the issues with detention facilities and escorting services (keeping reliable records of contract compliance and managing non-compliance robustly) so that they do not impact adversely on the ability of …
An inspection of Border Force operations at south coast seaports
In relation to immigration and customs threats to the south coast: a. regularly risk-test: cruise liner crewsRoll-on Roll-off (RoRo) freight arrivals at Southampton, including car transportersa representative sample of accompanied …
An inspection of Border Force operations at south coast seaports
Ensure that the reviews (Recommendations 1 and 2) take note of the concern that clandestine entrants are aware of and seek to exploit Border Force’s difficulties in dealing with multiple …
PPO death in custody recommendations(35)
The Governor of HMP Lincoln
The Governor should review Lincoln’s local guidance on medical emergency response codes to remind control room staff that, in the event of a medical emergency code, they should not wait for authorisation to request an ambulance.
Governors of prisons with MCBS units
Governors should ensure that: contingency plans are in place for a range of possible incidents in MCBS units; staff who may be called upon to act as Silver Commanders have received the appropriate training, including refresher training and have a …
The Governor of HMP The Mount
The Governor should ensure that all prison staff understand their responsibilities during medical emergencies, including that they: • use the appropriate emergency code when they discover a medical emergency; and • enter cells as quickly as possible when it is …
The Governor
ensure that staff understand the importance of calling the appropriate medical emergency code promptly.
The Governor
The Governor should conduct regular emergency response drills to allow staff to practice response requirements, including when to commence CPR.
The Governor of HMP Channings Wood
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that staff promptly use an emergency code to communicate the nature of the emergency and provide their correct location.
The Governor of The Mount
The Governor of The Mount should ensure that all staff understand their responsibilities about calling emergency codes so that emergency responses are timely.
The Governor of HMP Leyhill
The Governor should ensure that all staff are aware of the location of defibrillators and that they understand how to access and use them during a medical emergency.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should liaise with the local Ambulance Service to ensure that an effective protocol is in place so that the Ambulance Service understands the nature of medical emergencies in a prison context and that …
The Head of Healthcare
The Head of Healthcare should ensure that, once an emergency code blue has been called and an ambulance is on the way, staff should only stand it down if they are confident that the patient has fully recovered.
The Governor
The Governor should ensure that staff in the control room request an ambulance immediately when a medical emergency code is called.
The Governor
The Governor should ensure that all night staff carry individual emergency cell keys and enter cells as quickly as possible in a life threatening situation.
The Head of Healthcare
The Head of Healthcare should ensure that all emergency response equipment is regularly checked to ensure that the correct stocks of equipment and drugs are present to treat cardiac arrests.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should conduct a review of the emergency response to identify learning in relation to the errors and omissions identified and, facilitate training to rectify these issues.
The Head of Healthcare
The Head of Healthcare should ensure that there is always a registered nurse or a GP present during a medical emergency. Guidance on the role of GPs and senior managers during an emergency should be developed, detailing guidance on leadership, …
The Approved Premises Manager
ensure that staff err on the side of caution and call an ambulance immediately when a resident is found unresponsive and may have taken drugs;
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff use an appropriate code to communicate a medical emergency.
The Governor
The Governor should ensure there are a sufficient number of radios available to officers on each Unit.
The Head of Healthcare
The Head of Healthcare should ensure that the daily audit of the emergency bags includes checking that the equipment is in good working order.
The National Approved Premises Team
The National Approved Premises Team should ensure that residents receive appropriate supervision and support during the COVID-19 pandemic.
The Head of Healthcare
The Head of Healthcare should review the role of Hotel 1 to ensure that all healthcare staff that hold the Hotel 1 radio are aware of their role and responsibilities including how to manage situations when multiple codes are being …
The Head of Healthcare (HMP Styal)
The Head of Healthcare should ensure that staff understand how and when to administer adrenaline in medical emergencies and that they have received the appropriate training to do so.
The Governor and Head of Healthcare (HMP Styal)
The Governor and Head of Healthcare should review how staff are trained on the use of medical emergency codes and satisfy themselves that all staff are aware of their responsibilities during medical emergencies.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a suitable location where a prisoner can receive short-term 24-hour nursing care if required.
The Governor
The Governor should ensure that control room staff call an ambulance immediately when a medical emergency code is called.
The Governor of HMP Aylesbury
The Governor should ensure that all staff are aware of and understand their responsibilities during a medical emergency, including that information about the prisoner’s medical condition is provided to the control room in a timely manner.
The Governor of HMP Aylesbury
The Governor should review the Local Operating Policy for Emergency Response to include guidance for escorting an emergency ambulance during movements.
The Governor
The Governor should ensure there are sufficient first aid trained staff on duty at all times, in line with PSI 29/2015.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies including that staff: • use an emergency code immediately where there are serious concerns about the health of a prisoner to …
The Barnet, Enfield and Haringey Mental Health Trust Service Manager
The Barnet, Enfield and Haringey Mental Health Trust Service Manager should ensure that the RMN and all H3 staff are invited and have the opportunity to engage in a reflective session utilising the Practice Plus Group reflective presentation already completed. …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are aware of PSI 03/2013 and radio a medical emergency code in an emergency situation, including in the event of a fire.
The Head of Healthcare at HMP Hull
The Head of Healthcare at HMP Hull should ensure that the appropriate equipment, including a syringe pump, is available within the prison to support the delivery of safe and effective end-of-life care.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, including that staff enter cells as quickly as possible in life threatening situations.
The Director
The Director should ensure that staff understand that they can enter cells at night in medical emergencies without the permission of the night orderly officer in line with PSI 24/2011.
IOPC learning recommendations(10)
Recommendations - Thames Valley Police, May 2025
The IOPC recommends that Thames Valley Police (TVP) takes steps to ensure that frontline officers understand, and are confident in applying, guidance on method of entry. As part of this, the force should make clear the expectations on officers who …
Recommendations - West Midlands Police, July 2020
The IOPC recommends that West Midlands Police ensure adequate arrangements / contingencies are in place to ensure medical treatment is available in the event immediate medical assistance is required during pre-planned firearms operations. In this particular instance, immediate ambulance assistance …
Recommendations - Thames Valley Police, May 2025
The IOPC recommends that Thames Valley Police (TVP) should ensure method of entry equipment is available and easily accessible to police officers, so that whenever it may be required, entry can be gained to a property without undue delay. This …
Recommendations - West Midlands Police, July 2020
The IOPC recommends that West Midlands Police ensure the Force Control Room be formally notified and a log be created, with key details e.g. address, in advance of any firearms operations. Should additional resources or medical assistance be required, this …
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review the medical equipment available to officers and stored in police cars to ensure minimum standards of availability are maintained, including consideration of the availability of defibrillators. This follows an IOPC …
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review measures to be taken by control room staff in instances where emergency calls to third parties such as West Midlands Ambulance Service (WMAS) are placed on hold for a significant …
Recommendation - Thames Valley Police, June 2020
The IOPC recommends that Thames Valley Police consider what measures can be taken to improve Contact Management Centre resilience and increase support to staff; with particular regard to the practice of “patching together” Local Policing Area desks. This follows a …
Recommendation - Avon and Somerset Constabulary, June 2025
The IOPC recommends that Avon and Somerset Constabulary should put in place a process to ensure the control room telephone number is displayed to callers during a threat-to-life incident or a voice message is left enabling them to call back …
Recommendation - Sussex Police, January 2025
The IOPC recommends that Sussex Police update its call-handling training and guidance to include clear direction on when Contact Officers should seek specialist medical advice or support, particularly in cases where a sudden death is suspected. This follows an IOPC …
Recommendations - Greater Manchester Police, May 2024
The IOPC recommends that Greater Manchester Police reviews the current safeguards that are in place to prevent human error causing an unplanned server shutdown, within the force IT infrastructure, in the future, and ensures if it were to happen again, …
NAO audit recommendations(62)— showing 50 strongest matches
Increasing the capacity of the prison estate to meet demand
MoJ should combine thinking on policy objectives for the prison estate and improved evidence of different approaches to develop a long-term strategy to improve the resilience of the estate. It should: set out contingency plans for any unexpected increases in …
Accepted
The supply of personal protective equipment (PPE) during the COVID-19 pandemic
Emergency plans for dealing with a pandemic must provide for appropriate stockpiles of high-quality PPE together with comprehensive and resilient arrangements for the rapid procurement and distribution of PPE, based on reliable information. Plans need to include distribution of PPE …
Accepted
Progress delivering the Emergency Services Network
The Home Office should develop a contingency plan that sets out what it will do if technology on which the overall ESN programme is dependent does not work. The contingency plan should be linked to key delivery milestones for the …
Accepted
Resilience to animal disease
g ensure their disease outbreak plans are comprehensive and up-to-date, including updating disease-specific plans where required, ensuring plans cover responding to concurrent large exotic disease outbreaks and a scenario where capacity is insufficient, and developing a contingency plan for an …
Accepted
Increasing the capacity of the prison estate to meet demand
To provide greater transparency to the public and parliament, MoJ should commit to routinely publishing capacity projections alongside its demand projections. This should include outlining mechanisms for triggering contingencies to close capacity gaps, if higher-demand scenarios are realised.
Partially accepted
Lessons learned: tackling fraud and protecting propriety in government spending during an …
p) We recommend the Central Digital and Data Office work with departments and the Public Sector Fraud Authority to extend the remit of the essential shared data assets plan to: Consider what data-sharing arrangements could be set up now. In …
Accepted
Lessons learned: tackling fraud and protecting propriety in government spending during an …
n) We recommend the Central Digital and Data Office work with departments and the Public Sector Fraud Authority to extend the remit of the essential shared data assets plan to: Work out now what current datasets might be needed in …
Accepted
Lessons learned: tackling fraud and protecting propriety in government spending during an …
b) We recommend that departments, working with HM Treasury, Cabinet Office and the Public Sector Fraud Authority (PSFA): each develop internal ?how to guides? (?playbooks?) to aid future responses. These need to cover how governance can be streamlined when needed, …
Accepted
COVID-19 business grant schemes
The plans should include: the type of leadership, capabilities and governance arrangements that need to be in place as the emergency response evolves
Accepted
COVID-19 business grant schemes
The plans should include: the mechanisms for drawing upon local authority and departmental delivery expertise early in the design of the emergency support;
Accepted
COVID-19 business grant schemes
The plans should include: the data sources and analysis that might be needed at speed to assess the risk, determine how support might be targeted and the quantum of support needed;
Accepted
COVID-19 business grant schemes
The plans should include: the responsibilities for assessing the level of economic risk, identifying potential solutions and taking action;
Accepted
COVID-19 business grant schemes
HMT and DBT, working with local authorities, should by December 2023 draw up contingency plans to cover the provision of financial support to priority groups in the event of a future national emergency. The plans should draw upon the considerable …
Accepted
The Restart scheme for long‑term unemployed people
g) reduce the cost of scaling up and scaling down employment support. It should consider whether to maintain contracted-out employment support between economic shocks to maintain a market and to enable providers to more easily scale up capacity when it …
Accepted
The decommissioning of the AGR nuclear power stations
Given the impact that early closure of a station can have on the costs incurred by the Fund, the Department should, with EDFE, review the risks of early closure at each of the AGR stations to ensure appropriate contingency planning …
Accepted
The government’s preparedness for the COVID-19 pandemic: lessons for government on risk …
The Cabinet Office and HM Treasury should support departments to reduce variation in capacity, capability and maturity of risk management, emergency planning and business continuity across government departments. This should include providing advice on strengthening leadership of risk management, business …
Partially accepted
The government’s preparedness for the COVID-19 pandemic: lessons for government on risk …
The Cabinet Office and other government departments should ensure that lessons from simulation exercises are communicated and embedded across government. Simulation exercises are an effective way to spend resources to improve the management of low-probability high-impact risks, but lessons learned …
Accepted
The government’s preparedness for the COVID-19 pandemic: lessons for government on risk …
The Cabinet Office should strengthen oversight and assurance arrangements over preparations for system-wide emergencies. These should include publishing standards against which lead government departments, supporting departments and other public sector organisations can assess their level of preparedness for major emergencies, …
Accepted
The government’s preparedness for the COVID-19 pandemic: lessons for government on risk …
The Cabinet Office should work with government departments to ensure that their risk management, business continuity and emergency planning are more comprehensive, holistic and integrated. This involves ensuring that the government can rely on timely and good-quality data in the …
Accepted
The government’s preparedness for the COVID-19 pandemic: lessons for government on risk …
The Cabinet Office should support government departments to take stock of how funding for risk management and national resilience is prioritised and managed. There should be deliberate consideration of the investment required to ensure that risk management and national resilience …
Accepted
The government’s preparedness for the COVID-19 pandemic: lessons for government on risk …
The Cabinet Office should establish who leads and manages whole-system risks. Working with other departments, it should clarify and publicise the government’s risk appetite for whole-system emergencies as a basis for proportionate planning across government for these types of risk …
Partially accepted
The government’s approach to test and trace in England – interim report
b) plan against a range of plausible outcomes to ensure it has flexibility to respond to predictable and unexpected spikes in testing demand. Problems emerged when schools and universities reopened in September, despite a predictable spike in demand. NHST&T also …
Partially accepted
Achieving net zero
BEIS should: • prepare contingency plans that consider how to provide greater certainty and transparency around its net zero plans even if a full strategy is not possible prior to COP26 given the ongoing uncertainty around the impact of COVID-19.
Accepted
The supply of personal protective equipment (PPE) during the COVID-19 pandemic
The Department and its partners had to oversee and take many unplanned and unprecedented actions to obtain PPE during the emergency. Inevitably, some actions were more successful than others. A comprehensive lessons-learned exercise involving all the main stakeholders, including local …
Partially accepted
DCMS’s management of its COVID-19 loan book
DCMS should: b Assess future scenarios which may arise across the loan book and plan for a clear series of interventions for responding to different scenarios where loss of public money may be a risk. This work should feed into …
Partially accepted
Preparations to extend early years entitlements to working parents in England
For DfE to increase its chances of meeting forthcoming milestones it should: B) better use data to explore how variations in availability of early years places, parental take-up and workforce could impact future performance and costs. It should then set …
Accepted
Decarbonising the power sector
f) establish arrangements to understand and respond to system-wide risks and opportunities, to ensure its plan is resilient to setbacks, disruption and future uncertainty. This will involve having an overview of the cumulative demands on, for example, workforce, materials and …
Accepted
Decarbonising the power sector
In developing its delivery plan for power decarbonisation, DESNZ should: a) establish how it will ensure the system is resilient to prolonged periods of low generation from renewables. This should include considering the potential costs and benefits of maintaining some …
Accepted
Supporting investment into the UK
To mitigate risks to implementing its transformation programme, DIT should: ? consider what contingency plans may be needed to address capacity constraints that could affect the delivery and effectiveness of digital tools that are critical to DIT?s plans to achieve …
Accepted
The Restart scheme for long‑term unemployed people
DWP is likely to use an employment support scheme such as Restart again in the event of another economic shock. It should learn from the experience of Restart to ensure it is better prepared and able to scale up and …
Accepted
Government Shared Services
a) The Cabinet Office and clusters should first consider the feasibility of delivery, including any contingency plans should funding not be forthcoming. They should then take account of the following recommendations.
Accepted
Investigation into the Digital Services Tax
d) HMRC should develop a contingency plan for enforcement against business groups that do not have a physical presence in the UK and fail to engage with HMRC, after exploring the available options. This could include discussions with tax authorities …
Accepted
Delivery of employment support schemes in response to the COVID-19 pandemic
k) HM Treasury should ensure it develops robust plans for responding to economic shocks linked to health, environmental or other crises. Plans should be stress-tested to identify improvements and continually refined
Accepted
The Affordable Homes Programme since 2015
Before the end of 2022, the Department should: a, develop internal contingency plans in response to risks such as rising construction costs and a lack of bids from housing providers to deliver rural housing, to ensure it can fully meet …
Accepted
Managing cross-border travel during the COVID-19 pandemic
b) Departments should establish a clear system-level risk management framework to support government decision-making. The framework needs to be responsive to capture the dynamic and complex circumstances of the pandemic; informed by up-to-date data against relevant performance metrics, captured and …
Accepted
Managing cross-border travel during the COVID-19 pandemic
a) Departments should establish who is responsible for capturing and managing the risks for an overall system-based approach to COVID-19 or similar travel measures. Working together, departments should clarify the government?s risk appetite as a basis for any future cross-border …
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
• conduct a full lessons-learned exercise from its approach to fraud and error during COVID-19 and consider wider lessons from the pandemic for its processes and controls, balance of detection and prevention controls and future emergency planning.
Accepted
Test and trace in England – progress update
b) The Department and UKHSA should, by the end of December 2021, assess what standing capacity and infrastructure needs to be retained from NHST&T for future emergency responses, alongside plans for how this could be scaled up and down as …
Accepted
The government’s approach to test and trace in England – interim report
We highlight here the most significant risks and issues that NHST&T needs to address in the immediate future. It should: a) explore how to make fuller use of its theoretical maximum testing capacity each day, so that existing infrastructure and …
Partially accepted
Digital Services at the Border
b) check and plan for the implications of its mitigation actions if key elements of the programme are not ready or working effectively to the timescales it requires;
Accepted
The production and distribution of cash
The Bank should review its processes for deciding the appropriate level of contingency stocks and ensure that the factors weighed in reaching those judgements, along with the associated cost implications, are brought together and fully documented.
Accepted
Progress delivering the Emergency Services Network
The Home Office needs to work with other sponsors and users to develop the arrangements for managing ESN once it is fully operational. How the ESN service will be governed and managed when it is a live service is still …
Accepted
Progress delivering the Emergency Services Network
The Home Office needs to decide how the vital work to integrate all the ESN technology will be carried out. It should clearly set out whether this technical integration is part of the new contract for “programme advisory and delivery …
Accepted
Progress delivering the Emergency Services Network
The Home Office needs to test its overall programme plan, to determine whether the new schedule for launching ESN and shutting down Airwave is achievable. It should prepare a comprehensive plan as soon as possible, covering all key elements of …
Accepted
Investigation into how government is addressing antimicrobial resistance
The government should consider whether a national preparedness exercise with a significant AMR dimension should be carried out.
Accepted
Lessons learned: tackling fraud and protecting propriety in government spending during an …
m) We recommend that the Public Sector Fraud Authority develop and test a plan so that in an emergency it has the following: ? Clarity over the key counter-fraud priorities. This should build on the experience of providing the global …
Accepted
Investigation into the performance of UK Security Vetting
The Cabinet Office should ensure that there is sufficient resilience within UKSV to react to new events that might drive increased demand for security vetting
Accepted
Road enhancements: progress with the second road investment strategy (2020 to 2025)
In preparing for the third road investment strategy, DfT and National Highways should: improve the robustness of governance arrangements surrounding the contingency budget to ensure it is used in the way intended.
Accepted
Road enhancements: progress with the second road investment strategy (2020 to 2025)
In preparing for the third road investment strategy, DfT and National Highways should: further improvements to National Highways? approach to monitoring and managing portfolio risks. This should include: improvements to the iterative monitoring of the risks identified during development of …
Accepted
Planting Trees in England
d) establish plans for how to address a range of scenarios, including where tree-planting rates are falling short of targets, particularly how it will prioritise between the number of trees planted and the wider benefits that new trees should achieve;
Accepted
IMB annual reports(2)
East Sutton Park (2022)
This report for HMP East Sutton Park covers the period from November 2021 to October 2022. The Board finds the open women's prison to be largely safe and well-run, with good staff-resident relationships and effective resettlement efforts, particularly in securing external employment. Key concerns include the low population numbers hindering full use of capacity, residents arriving with insufficient time for resettlement, and the need to review fire evacuation procedures.
PRISON
Key concerns
North Sea Camp (2020)
HMP North Sea Camp is an open Category D prison noted for its rehabilitative culture and generally humane treatment of residents. The Board commends improvements in healthcare and positive staff-resident relationships, alongside community engagement. However, significant concerns remain regarding delays in Offender Management paperwork, inadequate accommodation conditions (including continued use of dormitories), and a lack of specific facilities for end-of-life and dementia care for the prison's increasing elderly population. These issues, alongside property transfer problems and laundry machinery breakdowns, require urgent attention and capital investment.
PRISON
Key concerns
IMB individual recommendations(38)
Heathrow Immigration Removal Centre (2022)
In light of the problems experienced during the November 2022 evacuation of Harmondsworth, e.g. lost possessions, inadequate emergency clothing and inadequate communication with detainees, we would urge the Home Office to ensure that the HIRC Contingency Plan is reviewed and is truly ‘fit for purpose’.
Home Office
Stafford (2021)
In order to protect residents and prison staff, will the Minister seek the elevation of prison staff to the equivalent of front line healthcare workers such that, should we ever experience another pandemic, they will be amongst the first groups provided with highly effective personal protective equipment (PPE) and vaccination/treatment?
Ministry of Justice
Implemented
Parc (2021)
Should there be further need for vaccinations for any form of Covid-19 or any other such pandemic, operational staff within the Prison Service should be treated as a priority group in order to protect the integrity of the service.
Ministry of Justice
Rejected
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That, with regard to Covid-19, an assessment is made of the capacity of the EDI and GLA HRs to provide safe distances between detainees and staff, and that maximum numbers are clearly displayed at the entrance to each HR.
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
As a first step, the temperature should be taken of those detainees who have not been tested for Covid-19 as they are accepted into the HRs. We would then expect that appropriate measures be taken to isolate those showing a high temperature.
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That, in light of the experiences learned from the Covid-19 pandemic, detailed epidemic/infection control plans, with actions, are shared with the IMB GEL. This practice should be adopted in any further outbreaks of contagious illnesses.
Home Office
South and East Short Term Holding Facilities (STHF) (2025)
As noted in 5.1, the Board recommends that the capacity at Luton Airport STHF is reviewed urgently, due to the potential impact on the safety of detained persons and staff in the event of a fire. It is not unusual to have more than 20 detained persons in a 24-hour period at Luton Airport, which is the stated capacity.
Home Office
Wayland (2021)
With regard to contingency planning, the Board believes that the lesson from the current pandemic is for the Prison Service to plan, on a national basis, for the maintenance of its core remit of enabling prisoners’ rehabilitation, and so avoid the current position of almost complete failure to address rehabilitative needs for more than the first year of the pandemic …
HMPPS
Noted
Wandsworth (2021)
Immigration service staff were absent throughout the period which caused considerable stress and hardship to foreign nationals, three of whom died during the period. What plans have been put in place to ensure that this most unsatisfactory situation is not repeated in the event of further Covid outbreaks?
Home Office
In Progress
Standford Hill (2025)
Staffing levels at night are very low, raising concerns about whether the prison is adequately resourced to respond effectively to unexpected incidents.
HMPPS
In Progress
Sudbury (2020)
Given the expectation that COVID-19 or similar new diseases are likely to pose problems for prisons in the medium to long term, are there plans to fund the extension of single room provision on a more permanent basis?
Ministry of Justice
In Progress
Sudbury (2020)
Given the ongoing threat to prisoner safety posed by COVID-19, will the minister produce a more robust policy on early release under licence?
Ministry of Justice
Noted
Springhill (2020)
In light of the pandemic, are processes about special licences and release on compassionate grounds to be reviewed, with more delegated authority to the Governor and consideration given to local risk assessment?
Ministry of Justice
Noted
Charter Flight (2020)
There must be no continued use of areas in an IRC from which people are collected for charters which expose them, or the escorts or any officials or observers present, to an environment which is unsafe under COVID-19 conditions (see paragraph 3.9.4).
Other
Wayland (2021)
The Board has been disappointed at the apparent inability to use pandemic-safe resources, such as the ‘Streetworks’ course, in the current operational response to the pandemic, and trusts that decisions can be taken, at both local and national levels, to plan for greater activity provision in future such emergencies (see section 7.2).
Governor / Director
Parc (2021)
Should there be further need for vaccinations for Covid-19 or any other such pandemic, operational staff within the Prison Service should be treated as a priority group in order to protect the integrity of the service. There was, at one stage, capacity within Cwm Taf Local Health Board to support vaccinations, but this was withdrawn by Public Health Wales (PHW).
Other
Rejected
Lewes (2021)
Will the Minister recognise the commitment of prison staff during the Covid-19 pandemic and ensure that a Covid recovery fund is available to restore facilities and services for prisoners and recognise the hard work of staff?
Other
In Progress
Heathrow and City airports Short Term Holding Facilities (2021)
The Board recommends that the maximum safe capacity of each holding room under social distancing conditions should be established by a public health expert and made known to all staff concerned, and that this limit should be strictly adhered to at all times. Plans should be put in place for an alternative holding area when these limits are exceeded.
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
We strongly recommend that, as a first step, UKBF, Immigration Enforcement (HOIE) and C&C undertake a technical risk assessment of their premise. Should the assessment advise that appropriate forced air ventilation be installed, we then urge that the work is given priority status. The desired outcome would be that the health and wellbeing of detained people and the staff working …
Home Office
Aylesbury (2022)
Improve forward planning, consultation and support to senior staff when prisons are required to house new categories of prisoner.
HMPPS
In Progress
North East Midlands, Yorkshire & Humber STHF (2023)
In the light of the unsafe arrival of a large intake of residents from Harmondsworth IRC in November 2022, we recommend that clear limitations are placed on both the vehicle size and number of residents who can arrive at the RSTHF at any one time.
Home Office
Exeter (2023)
Maintain the level of additional resources provided in response to the Urgent Notification?
HMPPS
Accepted
Yarl’s Wood IRC (2024)
There have been logistical issues when the CSU unit has been needed to be used by both male and female detained persons. The Board recommends that to avoid such problems, there should be a separate dedicated CSU for female detained persons.
Governor / Director
Partially Accepted
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
The use of the Controlled Waiting Area at Prestwick Airport is unacceptable when there is an alternative room that could be brought into use. While it may require additional resourcing bringing this room back use would facilitate hot food to be served to detailed persons.
Home Office
Hollesley Bay (2024)
The Board commends the induction unit and other staff for their response to the unexpected closure of Wilford unit for urgent maintenance and the need to relocate prisoners and the induction programme.
Governor / Director
Morton Hall IRC (2020)
During much of 2020, while in Command Mode and following instructions from HMPPS Gold Command, facilities such as the gymnasium and the place of worship were unable to be reopened at a time when such facilities were reopened in privately-operated IRCs and in the wider community. We understand the caution in relaxing restrictions given the potential higher risk of infection …
Other
Dartmoor (2020)
What planning is under way to support prisoners in the shielding unit through the trauma of eventual unshielding?
Governor / Director
Heathrow Immigration Removal Centre (2021)
The Home Office should fund a complete overhaul of the heating and ventilation system on both sites.
Home Office
Garth (2021)
Maintain a secure and safe environment through the remainder of the Covid pandemic.
Governor / Director
Coldingley (2021)
Would HMPPS consider allowing individual prison Governors increased delegated powers to progress more rapidly if local infection levels allow?
HMPPS
Implemented
London Heathrow and City Airports (2022)
[London City Airport] The Board recommends that further pressure be brought to bear on London City Airport managers to address the issue of the erratic temperatures being experienced in the holding rooms. (See paragraphs 6.3.4 and 6.3.5)
Home Office
Heathrow Immigration Removal Centre (2022)
In our 2021 annual report, we recommended that the Home Office fund a complete overhaul of the heating and ventilation systems on both HIRC sites. This recommendation was partially accepted, yet we are unaware of any attempt to deliver on this recommendation in any meaningful way. Given the significant impact of outages during 2022, culminating in the evacuation of the …
Ministry of Justice
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
That the appraisal of the ventilation arrangements at all facilities is undertaken as a matter of urgency.
Home Office
Aylesbury (2023)
Improve forward planning, consultation and support to senior staff when prisons are required to house new categories of prisoner.
HMPPS
Northumberland (2020)
Whilst the Board fully supports the protective measures deployed by the prison to proactively mitigate any potential negative consequences of the pandemic, we welcome the return to enhanced regimes and recommencement of social visits for the men at HMPN at the earliest possible opportunity.
Governor / Director
Feltham (2020)
What do you and your team consider to be the principal lessons learned over the lockdown period? How will the prison use these lessons to improve the lived experience for all young people and young adults held in custody at Feltham?
Governor / Director
Humber (2021)
As the pandemic has continued, the Board would have hoped that the Prison Service would have demonstrated greater flexibility in its approach to HMP Humber rather than retain the rigid adherence to stated stages of recovery imposed across the prison estate.
HMPPS
Humber (2023)
The Board would commend staff for the care they have given in cases during the reporting year, but feel it is an unreasonable demand on them and would ask the Prison Service to take all necessary steps to ensure such transfers are expedited.
HMPPS
In Progress
National patient safety alerts(1)
Health investigations(68)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (ix)
The Trust and Council should ensure that details of the contingency plan and crisis plan are made known to carers of the service user and any other persons who are voluntarily involved in the monitoring process and that they are provided with defined channels of communication to the mental health …
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (viii)
The Trust and Council should ensure that the care plan for a service user on Enhanced CPA includes a contingency plan and a crisis plan and that they contain the information prescribed in the CPA Policy Document.
london
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 15
The Trust should ensure that policies and procedures are developed with: the „blue light services‟ and that arrangements are formally agreed with them; and that the revised policies and procedures are incorporated into all statutory training events; and protocols to support emergency actions are produced on a simple A4 format …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 1
The Trust should review the emergency out of hours procedures and protocols and make formal written arrangements with each of the „blue light‟ services.
north_west
Independent investigation: Richard Marden, Towcester (1999) — Rec 15
That the Trust should introduce a scheme whereby a "Crisis Card" or something similar is provided to all users of the mental health services, and to all carers involved with mental health patients, giving details of the person(s) to contact in the event of an emergency.(Para 18.8)
midlands
Independent investigation: Faith Lovemore (6 wks), Cambridge (2009) — Rec 1
Where a person has the care of, or regular contact with, a baby or young child and s/he has a mental illness or it is reasonable to assume that their mental illness is likely to recur: • a clear crisis and contingency plan will be required and must be shared …
east_of_england
Independent investigation: David Huitson, Newcastle (2001) — Rec 8
The requirement of a contingency plan is in the Newcastle, North Tyneside and Northumberland Mental Health NHS Trust’s new CPA procedures and this should be audited to ensure that required actions by professionals following disengagement by patients are thoroughly implemented.
north_east_yorkshire
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 24
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a crisis plan, and that the crisis plan is agreed with the patient and their carers.
midlands
Independent investigation: Suryakant Patel, Harlington, London (2006) — Rec 2
It was the working assumption of the Assertive Outreach Team caring for the MHSU that if he was ‘picked up’ at an airport without any money, identification, or tickets to board a plane, then he would be taken to a place of safety and mental health services would therefore become …
north_east_yorkshire
Independent investigation: Robert Lewis, Sutton (2010) — Rec Eleven
It is recommended that the Trust review and establish robust procedures following such catastrophic events to ensure senior leadership oversees their response. This must include support and understanding for the local team, ensure professional medical leadership, organisational learning and awareness of the impact on patients, families, carers and the organisation, …
london
Independent investigation: Melanie Welch (Ms B), Redhill, Surrey (2001) — Rec 7.6
We recommend that the Trust ensures a robust system is in place for staff at the ‘Safe House’ to summon help to this stand alone unit.
south_east
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 2a
A written contingency plan is developed setting out the action to be taken if an emergency/deterioration in a patient’s condition occurs. This plan should be subsequently shared between the CMHT team, the patient’s General Practice, the patient and the patient’s carers (where appropriate).
wales
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec 3.24.5
That the trust and social services review their policies on providing a service to people who disengage, to build in contingency plans within the care planning, together with an age appropriate service.
london
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec 3.24.2
That the trust and social services review their policies on providing a service to people who disengage to build in contingency plans within the care planning, together with an age appropriate service.
london
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec R7
We recommend that if the police, or any other agency, are to be part of a care plan, including crisis planning, they must be informed of this, so that an action plan may be agreed in the event of contact being made.
london
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 7
We recommend that the grab pack highlights the nature and level of risk presented by a patient in simplified terms as a guide to appreciating the risk.
london
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 2
We recommend that the South London and Maudsley NHS Foundation Trust and Croydon Health Services NHS Trust meet, immediately, to establish sound and collaborative working relationships at a senior operational level, to develop clear, shared, agreed and understood policies for the management of medical emergencies for medium secure patients. These …
london
Independent investigation: Jean Robertson, Sittingbourne (2015) — Rec 8
The Trust must undertake further work with Swale Community Mental Health Team to ensure that crisis and contingency plans are in place and fully completed for all patients.
south_east
Independent investigation: Abdullah Jama, Blackheath (2009) — Rec 7
When service users are discharged to third sector or other organisations their support and care package should be formally agreed and there should be suitable robust contingency plans in place if service users go missing.
north_east_yorkshire
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 21
The Trust should develop a major strategic plan for the management of potentially catastrophic issues where public confidence in the organisation may be at stake in the light of unprecedented events. This will enable greater clarity and consistency in matters of communication, accountability and action (source: chapters eight and nine).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
Independent Investigation into the care and treatment provided to Mr … — Rec 4
The Trust should develop a protocol that ensures continuity of service when clinical teams experience disruption that have a direct bearing on the quality of patient care.
south_east
Assurance Review: Trust recommendations — Rec 25
Nephrostomy service • The Trust and Clinical Commissioning Groups (CCGs) should review arrangements for out-of-hours nephrostomy provision, including over bank holidays and emergency cover. • The arrangements that have been put in place should be assessed to ensure that standards for accessing nephrostomy provision out of hours and for returning …
north_west
An independent review of the care and treatment received by … — Rec R9
The trust and the police should work collaboratively to develop a critical incident MOU. This should include arrangements for establishing key roles and responsibilities for the management of the immediate response to an incident. This would enable the trust managers and the police to have a clear understanding of what …
north_east_yorkshire
Independent review into patient safety concerns and governance processes related … — Rec 3
Information regarding how to manually override a station gate to be added to stations in a location that is deemed to be easily accessible and in the same place in every station, for example, in the garage, near the garage door.
north_east_yorkshire
Independent review into patient safety concerns and governance processes related … — Rec 1
Trust wide communication to be issued via Operational Alert identifying how to manually override a station gate. Supporting information to include invoking business continuity should a station gate fail to open.
north_east_yorkshire
Independent investigation report into the care and treatment of Mr … — Rec 7
DHCFT should ensure that the Trust emergency management/business continuity plans include serious interruption of services and that there is a structure to ensure such occurrences are managed with appropriate leadership and senior oversight.
midlands
Accepted
Independent investigation into the care and treatment of Mr M … — Rec 7
This investigation fully supports the recommendation from the EPUT investigation that the Trust should ensure all failed urgent home visits are communicated to a team leader or equivalent to agree an appropriate plan of action including, if necessary, the use of out of hours services.
east_of_england
An independent investigation into the care and treatment of Thomas: … — Rec 2
The ambulance service must achieve reliability and consistency across all its response teams regarding the practice of safety-netting when a decision is made not to transfer an individual to hospital. Safety-netting is where the responding crew make sure that appropriate steps are put in place to assure the ongoing safety …
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 4
Given the clinical findings, a pre-alert should have been sent to the receiving hospital, but this did not take place. Pre-alert protocols must be adhered to so that receiving hospitals can prepare for and respond appropriately to the arrival of very sick patients.
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec r.
That Birmingham City Council, the PCTs and the police should consider the need to establish a local control room staffed by Punjabi and Urdu- speaking operators for the purpose of dealing with police, ambulance and health calls from non-English speaking members of the community. This might involve non-English speakers dialing …
midlands
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 18
When a patient goes AWOLfrom compulsory detention under the MHA, a contingency plan should be drawn up which includes a requirement for the patient to be re-assessed if he comes to the attention of any of the local services.
london
Independent investigation: Stuart Hopkin, Shepton Mallet (2020) — Rec 4
Protocol for emergency access to a medium secure mental health bed. The Trust, in collaboration with provider collaborative forensic services, must ensure that the protocol for emergency access to a medium secure mental health bed is adhered to by clinicians, specifically in relation to: a) its purpose and when it …
south_west
Independent investigation: Natasha Wild, Rochdale (2016) — Rec 1
The one issue arising from this case that cannot be allowed to continue is the lone working situation for adult and children’s emergency duty teams. How these teams can be co-located with other out of hours mental health teams must be explored. It simply does not make logical sense for …
north_west
Independent investigation: Lee Johnson, Newcastle (2003) — Rec 4
Any risk assessment must be fully documented in a readily identifiable document and include the risk management plan including crisis/contingency plans.
north_east_yorkshire
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 5b
Where appropriate, families and/or carers of patients are fully informed about the decisions and plans in place for patient care, including effective communication of any subsequent discharge or contingency plans.
wales
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 17
A risk management policy or guidelines should be implemented for Alexandra Road detailing the steps to be taken in a crisis.
london
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 14
That RMOs (now Responsible Clinicians, RCs) complete Section 17 leave forms when any detained patient is granted leave for any purpose. That a copy of the care plan, outlining appropriate measures to protect the public, be placed, for the guidance of the escorting nurses, in the ‘grab pack37’ which is …
london
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 12
Nursing leadership and historically high churn rates within the nursing team is a known risk to the Trust for this service. A contingency plan should be in place for managing the risks incurred when senior positions in the team are vacant to ensure stability on the unit. The practice of …
london
Independent investigation: Chloe Fahey, Manchester (2003) — Rec O.6
It is recommended that all Station Sergeants have, readily accessible, the telephone number of the Emergency Duty Team from Social Services for them to give out in appropriate circumstances to members of the public.
north_west
Independent investigation: Chloe Fahey, Manchester (2003) — Rec D.1
It is recommended that information about working hours/availability of care co-ordinators should be made available to patients and carers and include contact arrangements both in, and out of, working hours in the event of the co-ordinator being unavailable.
north_west
Independent Investigation into the care and treatment provided to Mr … — Rec 5
The Trust should ensure that additional clinical guidance is given to EIIP Teams in relation to levels of assertive engagement required. The need for additional levels of engagement should always be considered when risk assessment planning has not been conducted in a regular manner and when service continuity issues are …
south_east
Assurance Review: Trust recommendations — Rec 43
Emergency theatre access • The Trust should monitor the use of emergency theatres out of hours in Urology (building on the analysis provided in this report) to establish whether the existing Standard Operating Procedure (Theatre Access) is effective in changing the pattern of practice highlighted by this report. • This …
north_west
Assurance Review: Trust recommendations — Rec 40
Implement clinical audit programme (Link to R4, R9, R14, R18, R25, R41, R47) A standard should be set for each of the following against which a clinical audit programme should be implemented: • Handover quality • Emergency surgery including access to and use of theatres out of hours • Emergency …
north_west
An independent review of the internal investigation and associated action … — Rec 8
The Trust must undertake further work with Swale Community Mental Health Team to ensure that crisis and contingency plans are in place and fully completed for all patients.
south_east
Partially Accepted
An Independent Investigation into the care and treatment of Mr … — Rec 5
The Trust should ensure that appropriate processes are in place to agree contingency arrangements for staffing shortages.
midlands
An independent investigation assurance review (published June 2021) can be … — Rec 5(a)
A quick summary including a snapshot of all known historic risk factors, risk factors and relapse signature and contingency plan should be available and updated at every point of review, transfer and made available to all members of the team;
north_east_yorkshire
An assessment of a mental health trust’s internal investigation of … — Rec R10
The Trust should ensure that the impact of external factors, such as the Covid-19 pandemic, on service delivery and effective risk management is thoroughly examined in future investigations, to maximise learning and inform resilience planning.
north_east_yorkshire
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 5
The Metropolitan Police Service and mental health service providers and users should jointly review their arrangements for responding to potentially violent mentally ill persons in the community, with a view to developing a joint policy and operational protocol for managing such incidents. This should include clear guidelines on risk assessment, …
london
Independent investigation: Michael Kahan, Manchester (2008) — Rec 9
The Trust should ensure that carers, when included in the care plan for a service user, are aware of the plan, have a written copy of the plan and have a contingency plan if things go wrong.
north_west
Independent investigation: John Stevens, Woking (2001) — Rec 18
We recommend that North West Surrey Mental Health Partnership Trust reviews the serious incident policy to a) Include the attendance of the oncall senior manager at the scene of the incident as soon as possible to take immediate action in supporting staff and patients and securing the notes to make …
south_east
Scottish Fatal Accident Inquiries(8)
Amanda Duncan
The Fire Brigade should review the standard command instructions and reinforce training especially with BA teams so that those who give and those who receive instructions have no scope in the future for such misunderstanding. In any event, and for the avoidance of doubt henceforth, it is my very clear opinion that firefighters should be required on an annual basis …
Mar 1999
Police Constable Lewis Fulton
I make no specific recommendation in this regard but it does appear to me that the system of communication with dog handlers is one which ought to be re-examined.
Jan 2003
Alison Hume
Interpretation of what constitutes “a structure” in terms of undertaking a rescue ought to be defined expansively. If anything, the additional functions of Section 4 of the SI infer a requirement to prepare and plan for subsurface operations, and therefore “structures” should be interpreted, not only to include an edifice or building, but any manmade or engineered construction which ought …
Nov 2011
Pjero Kurida
In terms of section s26(1)(b) (recommendations, if any, as to the taking of any other steps, which might realistically prevent other deaths in similar circumstances): Those responsible for operating merchant vessels in UK waters should have in place the necessary training, guidance, procedures and rules to ensure informed and appropriate responses to medical incidents of uncertain severity. These measures should …
Feb 2022
Matthew Peter Burden
(i) Tillypronie Estate to introduce a system of working whereby the head gamekeeper or other senior member of staff is charged with the duty of checking the 7 day weather forecast as published on the Met office website in the 7 day period leading up to the date of shoots booked to take place on the estate, to include a …
Jun 2026
Craig Currie, William Carty, Stephen Carty and Thomas Douglas
And further recommends (i) That a register of local assistance which excludes the ambulance service be made up by Strathclyde Police and circulated to the emergency services and that the register includes the names of persons and equipment available to be called upon in an emergency rescue situation. (ii) That in the event of an emergency involving Strathclyde Police and …
Oct 2011
Brendan Reilly
It is recommended that HMP Kilmarnock review the arrangements for ensuring and monitoring compliance with the roll count policies and procedures. It is recommended that HMP Kilmarnock should comply with the recommendation made by the Significant Adverse Event Review, namely to implement an effective policy concerning communication for requesting an ambulance in emergency situations.
Apr 2025
Custody
2 recs
Leo Lamont; Ellie McCormick; Mira-Belle Bosch
1. Recommendation 1: Greater Glasgow & Clyde Health Board (“GGCHB”) should develop a trigger list or similar system to (a) aid in the identification and assessment of symptoms that might be indicative of preterm labour and (b) inform a decision as to whether a patient should attend for clinical assessment. When a telephone assessment is carried out with a patient …
Mar 2025
Health
11 recs
Article 2 learning points(3)
— LP 7
We recommend that a local contingency plan is put in place for the steps to be taken in the event of an emergency. This should include notification of court security staff when an ambulance has been called and that a member of staff able to report changes in the patient’s …
HMPPS
Accepted
— LP 5
We invite the Governor to examine whether the 12 minutes from arrival at the prison to attending a patient on K wing is unavoidable or whether the process of accessing the wings in emergencies can be made more efficient.
HMPPS
Accepted
— LP 4
We recommend that the Governor of Stocken (locally) and HMPPS (nationally) review the present arrangements for communications with the ambulance services to examine whether current policy and practice appropriately reflects the ambulance services’ system of allocating priorities.
HMPPS
Accepted
Detention investigations(10)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 2
IND and the Prison Service give further consideration to contingency arrangements to ensure greater clarity and proper lines of accountability, and which, ideally, give IND ultimate authority and responsibility for the management of incidents. Failing this, I recommend a small cadre of potential Gold Commanders be prepared/trained specifically for handling …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 71
Group 4 builds into its contingency plans reference to the need to follow proper procedures and to complete relevant paperwork in the aftermath of a serious incident.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 69
IND ensures that a requirement immediately to inform the IMB of any major incident should be incorporated in each contractor’s contingency plans.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 72
contract monitors receive additional briefing on what to monitor and how to enforce compliance following a serious incident.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 70
IND/the IMB Secretariat circulates fresh advice both to contract monitors and Independent Monitoring Boards about their role during a major incident.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 7
IND ensures plans and other relevant documents for each centre are placed in the Prison Service Gold command suite.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 29
I recommend that IND urgently reviews the use of, and conditions in, the Queen's Building at Heathrow.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 28
I recommend that IND consults with BAA about ways of accelerating entry to Heathrow.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 15
GSL reviews its fire contingency plans to ensure they are appropriate and offer adequate protection for detainees and staff.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 12
• Contractors be required to draw up and implement action plans following any serious incident. The plans should incorporate all lessons learned and, where those lessons are generic, should be applied across all the contractor’s centres; • IND monitors implementation within agreed timescales; • IND ensures that contractors prepare contingency …
Immigration Detention
Independent reviews(50)
Cunliffe Water Commission — Rec 66
Recommendation 66: Statutory resilience standards, covering system, infrastructure and supply chains, should be developed and adopted for the water industry in England and Wales. Resilience standards should ensure all companies make forward-looking, long-term assessments of their systems and assets and of their ability to recover from disruption to their network.
Other
Cunliffe Water Commission — Rec 59
Recommendation 59: The regulator in England and Wales should develop and consult on a framework for ensuring companies are prepared for SAR.
Other
Jones: Patronising Disposition Review — Rec 4
The families' experience demonstrates the need for social work and other support to be made available at the earliest opportunity following a public disaster. That support should be capable of referring on bereaved families to relevant support in the area in which they live. I believe that this will be …
Policing & Security
Jones: Patronising Disposition Review — Rec 2
The experience of the Hillsborough families as set out in chapter 1 identifies specific failures in the response to the disaster in 1989. The material in that chapter presents an opportunity for police forces, the College of Policing, coroners and the Chief Coroner to undertake an honest self-appraisal of their …
Policing & Security
Pitt Floods Review — Rec 92
Local Resilience Forums should evaluate and share lessons from both the response and recovery phases to inform their planning for future emergencies.
Other
Pitt Floods Review — Rec 88
The Government should establish a National Resilience Forum to facilitate national level multi-agency planning for flooding and other emergencies.
Other
Pitt Floods Review — Rec 84
Central government should have pre-planned rather than ad-hoc arrangements to contribute towards the financial burden of recovery from the most exceptional emergencies, on a formula basis.
Other
Pitt Floods Review — Rec 80
All central government guidance should be updated to reflect the new arrangements for recovery and Local Resilience Forums should plan, train and exercise on this basis.
Other
Pitt Floods Review — Rec 79
Government Offices, in conjunction with the Local Government Association, should develop arrangements to provide advice and support from experienced organisations to areas dealing with recovery from severe flooding emergencies.
Other
Pitt Floods Review — Rec 78
Aims and objectives for the recovery phase should be agreed at the outset by Recovery Coordinating Groups to provide focus and enable orderly transition into mainstream programmes when multi-agency coordination of recovery is no longer required.
Other
Pitt Floods Review — Rec 77
National and local Recovery Co-ordinating Groups should be established from the outset of major emergencies and in due course there should be formal handover from the crisis machinery.
Other
Pitt Floods Review — Rec 76
Local authorities should coordinate a systematic programme of community engagemment in their area during the recovery phase.
Other
Pitt Floods Review — Rec 75
For emergencies spanning more than a single local authority area, Government Offices should ensure coherence and coordination, if necessary, between recovery operations.
Other
Pitt Floods Review — Rec 74
The monitoring of the impact of flooding on the health and wellbeing of people, and actions to mitigate and manage the effects, should form a systematic part of the work of Recovery Coordinating Groups.
Other
Pitt Floods Review — Rec 73
The Government, the Association of British Insurers and other relevant organisations should work together to explore any technological or process improvements that can be made to speed up the drying out and stabilising process of building recovery after a flood.
Other
Pitt Floods Review — Rec 72
Local response and recovery coordinating groups should ensure that health and wellbeing support is readily available to those affected by flooding based on the advice developed by the Department of Health.
Other
Pitt Floods Review — Rec 70
The Government should establish a programme to support and encourage individuals and communities to be better prepared and more self-reliant during emergencies, allowing the authorities to focus on those areas and people in greatest need.
Other
Pitt Floods Review — Rec 64
Local Resilience Forums should continue to develop plans for door-knocking, coordinated by local authorities, to enhance flood warnings before flooding and to provide information and assess welfare needs once flooding has receded.
Other
Pitt Floods Review — Rec 57
The Government should provide Local Resilience Forums with the inundation maps for both large and small reservoirs to enable them to assess risks and plan for contingency, warning and evacuation and the outline maps be made available to the public online as part of wider flood risk information.
Other
Pitt Floods Review — Rec 56
The Government should issue clear guidance on expected levels of Category 2 responders’ engagement in planning, exercising and response and consider the case for strengthening enforcement arrangements.
Other
Pitt Floods Review — Rec 55
The Government should strengthen and enforce the duty on Category 2 responders to share information on the risks to their infrastructure assets, enabling more effective emergency planning within Local Resillience Forums.
Other
Pitt Floods Review — Rec 54
The Government should extend the duty to undertake business continuity planning to infrastructure operating Category 2 responders to a standard equivalent to BS25999, and that accountability is ensured through an annual benchmarking exercise within each sector.
Other
Pitt Floods Review — Rec 52
In the short-term, the Government and infrastructure operators should work together to build a level of resilience into critical infrastrucure assets that ensures continuity during a worst-case flood event.
Other
Pitt Floods Review — Rec 51
Relevant government departments and the Environment Agency should work with infrastructure operators to identify the vulnerability and risk of assets to flooding and a summary of the analysis should be published in Sector Resilience Plans.
Other
Pitt Floods Review — Rec 50
The Government should urgently begin its systematic programme to reduce the disruption of essential services resulting from natual hazards by publishing a national framework and policy statement setting out the process, timescales and expectations.
Other
Pitt Floods Review — Rec 49
A national flooding exercise should take place at the earliest opportunity in order to test the new arrangements which central government departments are putting into place to deal with flooding and infrastructure emergencies.
Other
Pitt Floods Review — Rec 48
Central government crisis machinery should always be activated if significant wide-area and high-impact flooding is expected or occurs.
Other
Pitt Floods Review — Rec 47
The Ministry of Defence should identify a small number of trained Armed Forces personnel who can be deployed to advise Gold Commands on logistics during wide-area civil emergencies and, working with Cabinet Office, identify a suitable mechanism for deployment.
Other
Pitt Floods Review — Rec 46
The rail industry, working through Local Resilience Forums, should develop plans to provide emergency welfare support to passengers stranded on the rail network.
Other
Pitt Floods Review — Rec 45
The Highways Agency, working through Local Resilience Forums, should further consider the vulnerability of motorways and trunk roads to flooding, the potential for better warnings, strategic road clearance to avoid people becoming stranded and plans to support people who become stranded.
Other
Pitt Floods Review — Rec 44
Category 1 and 2 responders should assess the effectiveness of their emergency response facilities, including flexible accommodation, IT and communications systems, and undertake any necessary improvement works.
Other
Pitt Floods Review — Rec 43
Gold Commands should be established at an early stage on a precautionary basis where there is a risk of serious flooding.
Other
Pitt Floods Review — Rec 42
Where a Gold Command is established for severe weather events, the police, unless agreed otherwise locally, should convene and lead the multi-agency response.
Other
Pitt Floods Review — Rec 41
Upper tier local authorities should be the lead responders in relation to multi-agency planning for severe weather emergencies at the local level and for triggering multi-agency arrangements in response to severe weather warnings and local impact assesments.
Other
Pitt Floods Review — Rec 40
Defra should amend emergency regulations to increase the minimum amount of water to be provided in an emergency, in order to reflect reasonable needs during a longer-term loss of mains supply.
Other
Pitt Floods Review — Rec 39
The Government should urgently put in place a fully funded national capability for flood rescue with Fire and Rescue Authorities playing a leading role, underpinned as necessary by a statutory duty.
Other
Pitt Floods Review — Rec 38
Local authorities should establish mutual aid agreements in accordance with the guidance currently being prepared by the Local Government Association and the Cabinet Office.
Other
Pitt Floods Review — Rec 34
The Met Office and the Environment Agency should issue warnings against a lower threshold of probablity to increase preparation lead times for emergency responders.
Other
Pitt Floods Review — Rec 33
The Environment Agency should provide a specialised site-specific flood warning service for infrastructure operators, offering longer lead times and greater levels of detail about the velocity and depth of flooding.
Other
Pitt Floods Review — Rec 18
Local Surface Water Management Plans, as set out under PPS25 and coordinated by local authorities, should provide the basis for managing all local flood risk.
Other
Pitt Floods Review — Rec 13
Local authorities, in discharging their responsibilities under the Civil Contingencies Act 2004 to promote business continuity, should encourage the take-up of property flood resistance and resilience by businesses.
Other
Pitt Floods Review — Rec 6
The Environment Agency and the Met Office should work together, through a joint centre, to improve their technical capability to forecast, model and warn against all sources of flooding.
Other
Harris Review: Deaths in Custody — Rec 84
Each prison and YOI should have an emergency medical response plan that contains the following elements: 84.1 A mandatory Medical Emergency Response exercise each year, including emergency medical codes, in conjunction with local health care providers and emergency services. 84.2 NHS needs to consider developing an appropriate health “NEVER” event …
Justice & Legal
Skeoch Review — Rec 7
The Bank of England should ensure that sufficient plans are in place as part of its contingency planning to provide liquidity to NRFBs in a stress scenario.
Other
Turner Review — Rec 13
A resolution regime which facilitates the orderly wind down of failed banks should be in place (already done via Banking Act 2009).
Other
IOPC Review — Rec 23
The IOPC should review the resilience and adequacy of its on-call arrangements, including whether further bespoke training should be offered to those who are on-call and whether it may be preferable to have a dedicated team or unit providing this service, in common with how many government departments and operational …
Policing & Security
Kerslake Review — Rec 46
Standardised contingencies should be developed by all councils to enable an official fund to be established urgently following any future incident that attracts financial donations from the public, as was done in Manchester, to avoid misappropriation of donations and to ensure fair distribution of funds
Policing & Security
Accepted
Kerslake Review — Rec 44
In the immediate aftermath of a mass fatalities incident, police forces should consider how they might establish effective arrangements for the collection, collation and retrieval of potential casualty data, during the inevitable period between the event occurring and the Casualty Bureau being fully operational. These arrangements should be made public …
Policing & Security
Accepted
Kerslake Review — Rec 39
Emergency plans for major incidents should incorporate comprehensive contingencies for the provision of mental health support to adults, children and young people, families and responders
Policing & Security
Accepted
Kerslake Review — Rec 37
All major transport hubs and public venues should possess and provide immediate access to basic frameless canvas stretchers to enable rapid movement and evacuation of casualties during terrorist attacks or other high-threat or dynamic-hazard incidents
Policing & Security
Accepted
PHSO casework decisions(29)
P-003558 — Leeds Teaching Hospitals NHS Trust
Mrs A complained her husband received incorrect ED treatment, wrong referral, an ECHO despite breathlessness causing cardiac arrest, and poor communication before his death.
NHS in England
May 2025
P-003257 — Buckinghamshire Healthcare NHS Trust
Mrs E complained her son was sent home from A&E without a diagnosis for chest pains, dying later that day, alleging this failure led to his death.
NHS in England
Dec 2024
P-003231 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr U complained his wife suffered delayed nebuliser treatment, incorrect cannula insertion, missed swallow assessment, poor hygiene, and steroid overdose, resulting in infection and mini-strokes.
NHS in England
Dec 2024
P-003783 — South East Coast Ambulance Service NHS Foundation Trust
Mrs V complained the Ambulance Trust completed a welfare call instead of arranging an ambulance for her mother, delaying treatment and contributing to her death.
NHS in England
Aug 2025
P-004067 — East of England Ambulance Service NHS Trust
Mr L complained that his friend's 999 call was triaged incorrectly and an ambulance delay occurred, and that the ambulance crew refused to take his wheelchair during a hospital transfer.
NHS in England
Sep 2025
P-004547 — University Hospitals Sussex NHS Foundation Trust
Mr B complained about delayed observations, incomplete initial assessment, and delayed sepsis screening and treatment for his mother at the Trust's Emergency Department.
NHS in England
Partly Upheld
Dec 2025
P-004654 — South Western Ambulance Service NHS Foundation Trust
The ambulance service delayed sending an ambulance, prevented a rapid response vehicle from attending, and failed to understand the seriousness of her son's breathing difficulties, leading to his death.
NHS in England
Partly Upheld
Jan 2026
P-001604 — Isle of Wight NHS Trust
Mr P complained the Trust left him unattended for several hours, causing him to feel unsafe, leading to stress and negative mental health effects.
NHS in England
Nov 2022
P-001859 — East and North Hertfordshire NHS Trust
Mrs N complained the Hospital Trust provided inappropriate care in the ED, including inadequate examination, missed sepsis, premature discharge without medication, and lost notes, all contributing to her father's pain and worsened condition before his death.
NHS in England
Upheld
Mar 2023
P-003279 — Torbay and South Devon NHS Foundation Trust
Mrs L complained about a 13-hour ambulance wait for her mother, delayed admission, failure to perform an endoscopy, and that an injection may have hastened her mother's death.
NHS in England
Partly Upheld
Jan 2025
P-003595 — North Cumbria Integrated Care NHS Foundation Trust
Mr A complained North Cumbria Integrated Care NHS Foundation Trust failed to quickly identify his mother's serious condition in ED, delayed moving her to critical care, and lost blood tests, impacting her cognitive function.
NHS in England
Not Upheld
Jun 2025
P-003628 — North East Ambulance Service NHS Foundation Trust
Miss J complained about ambulance call handling delays and insufficient advice for her father's cardiac arrest, believing it reduced his survival chances and caused distress.
NHS in England
Partly Upheld
Jun 2025
P-003689 — The Rotherham NHS Foundation Trust
Mrs G complained about her son Mr M's care, including a referral to ED, lack of isolation, delayed insulin, inability to self-administer medication, and delayed COVID-19 testing, believing these caused his death.
NHS in England
Jul 2025
P-003644 — University Hospital Southampton NHS Foundation Trust
Complainants alleged their father received inadequate ED care, including delayed assessment, missed diagnosis of aortic dissection, and delays in monitoring and pain relief, contributing to his death.
NHS in England
Jul 2025
P-003815 — London Ambulance Service NHS Trust
Mr L complained the Ambulance Service failed to recognize his mother's stroke symptoms, and the Hospital Trust delayed her assessment and transfer, contributing to her death.
NHS in England
Not Upheld
Aug 2025
P-003973 — South East Coast Ambulance Service NHS Foundation Trust
Mrs L complained the Trust did not take her concerns seriously about her brother's breathlessness and heart condition, resulting in him not being conveyed to hospital and dying at home.
NHS in England
Sep 2025
P-004018 — North West Anglia NHS Foundation Trust
Miss M complained her mother did not receive appropriate care for constipation, and that a perforated bowel and sepsis were not diagnosed and treated quickly enough, leading to her death.
NHS in England
Partly Upheld
Sep 2025
P-004271 — Lewisham and Greenwich NHS Trust
Mr L complained Lewisham and Greenwich NHS Trust denied him essential treatment and left a cannula in his arm. He also alleged London Ambulance Service paramedics were disrespectful and refused his hospital choice.
NHS in England
Nov 2025
P-004740 — Hampshire Hospitals NHS Foundation Trust
Mr G's family complained about delayed cancer diagnosis due to GP telephone consultations, lack of Macmillan nurse referral, and restricted visiting and discharge to a care home at the Hospice.
NHS in England
Not Upheld
Jan 2026
P-004687 — Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust delayed investigations into her son's gastrointestinal bleeding, lacked staff, delayed transfer, and provided inconsistent complaint responses, contributing to his death.
NHS in England
Not Upheld
Jan 2026
P-001139 — Chelsea and Westminster Hospital NHS Foundation Trust
Miss A complained the Trust failed to arrange apologies, disregarded her concerns about moving her vulnerable, shielding son, and did not answer her complaint questions.
NHS in England
Oct 2021
P-001342 — Planning Inspectorate
Mrs E complained a PINS Inspector visited her property unannounced and against COVID-19 guidelines while she was shielding, causing agitation to her husband and health risk.
UK Government
Not Upheld
Mar 2022
P-003583 — Calderdale and Huddersfield NHS Foundation Trust
Mrs A complained Huddersfield Royal Infirmary failed to provide pain relief or a bed for her husband. She also complained paramedics and a GP failed to provide adequate care at home.
NHS in England
Jun 2025
P-003612 — East of England Ambulance Service NHS Trust
Mr E complained the hospital discharged his mother when unfit, lacked a care plan, delayed transfer to critical care, removed a drip, and didn't transfer her. He also complained the ambulance crew incorrectly assessed her.
NHS in England
Jun 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-003602 — Stockport NHS Foundation Trust
Miss L complained about delayed cardiology consultation and incorrect treatment for her mother in A&E, believing these failings contributed to her mother's death.
NHS in England
Not Upheld
Jun 2025
P-003634 — Frimley Health NHS Foundation Trust
Mrs E complained about three Trusts, alleging premature oxygen, transfers worsening his condition, rapid deterioration, improper ventilator placement, and poor post-death administration.
NHS in England
Jun 2025
P-001734 — Environment Agency
Mr R and Mrs B complained about the Environment Agency's waterway fee policy during the pandemic, as they paid fees but could not use the waterway. They sought a refund.
UK Government
Jan 2023
P-001983 — Hampshire Hospitals NHS Foundation Trust
Ms C complained about poor communication, forced DNACPR, delayed physiotherapy, incorrect medical statements, abrupt treatment cessation, and inadequate documentation regarding her father's care.
NHS in England
May 2023
LGO / SPSO decisions(80)
PSOW-202302509 — Welsh Ambulance Services NHS Trust
Ms Z complained about the appropriateness of the categorisation given by Welsh Ambulance Services NHS Trust (“the Trust”) to an emergency call made by her father in August 2022. Ms Z also complained about the appropriateness of a welfare check made by the Trust, specifically whether further questions should have …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202204639 — Welsh Ambulance Services NHS Trust
We investigated a complaint by Mr A about the delay in obtaining an Out of Hours GP visit for his late wife, Mrs A, which was requested via 111. Specifically, we considered whether Mrs A’s symptoms were appropriately assessed by the 111 service, which is provided by the Trust, and …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202202481 — Welsh Ambulance Services NHS Trust
Mrs A complained about Welsh Ambulance Services NHS Trust (“WAST”) and Swansea Bay University Health Board (“the Health Board”). The investigation considered Mrs A’s complaint about the care her late husband, Mr B, received from WAST. Mrs A complained about the delay in an ambulance arriving following her 999 calls …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
20-007-315 — HC-One Oval Limited
Summary: Mrs X complains HC-One Oval Limited’s Lyndon Hall Nursing Home failed to look after her late mother properly and failed to keep her family informed about the deterioration in her condition before she died, causing unnecessary distress. HC-One accepts Lyndon Hall failed to deal properly with two falls and …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-007-170 — Westminster City Council
Summary: Mr F complained about the actions of the Council and its leisure contractor. We found the Council at fault for having an unclear complaint process and for its responses to Mr F’s concerns. These caused Mr F distress and put him to unnecessary time and trouble. The Council accepts …
LGO (Local Government & …
Other Categories
Upheld
May 2022
20-010-783b — Gloucestershire Hospitals NHS Foundation Trust (20 010 783b)
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Health
Upheld
May 2022
20-010-783a — Gloucestershire Hospitals NHS Foundation Trust (20 010 783a)
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Health
Upheld
May 2022
21-011-155 — Wakefield City Council
Summary: Ms X complained about lack of education and support for her son, C, under his Education, Health and Care Plan while he was out of school during the COVID-19 pandemic because of his vulnerability to risk of infection. We find that at first the Council took reasonable steps to …
LGO (Local Government & …
Education
Upheld
Aug 2022
20-010-354 — North Yorkshire County Council
Summary: Ms X complains about the care her late mother received in Leeming Bar Grange Care Home, where the Council funded her placement from September 2019. The Council was at fault because the Care Home was not open with Ms X about her mother’s declining condition and, when advised to …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-004-272 — Poole High School
Summary: Mrs X complains that an appeal panel did not properly consider her appeal for a place at a school. We find the School is at fault as there is no evidence to show the appeal panel made a decision on whether the admission arrangements were lawful. This fault did …
LGO (Local Government & …
Education
Upheld
Dec 2022
201102504 — Scottish Ambulance Service
Mr A had abdominal pain in the early hours one morning. The pain had been present the previous day, but had got much worse. Mr A's wife (Mrs C) contacted the ambulance service for assistance, but they did not send an ambulance so Mrs C took her husband to hospital. …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201300720 — Scottish Ambulance Service
Mrs C's husband (Mr C) cut his hand in an accident at home. She dialled 999 and asked for an ambulance. The ambulance service's call handler took details of Mr C's injury but concluded that an ambulance was not necessary. Mrs C had to ask neighbours to help transport Mr …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2014
201807508 — Scottish Ambulance Service
Mr C called an ambulance after finding his wife (Mrs A) in a concerning condition. The ambulance took longer to arrive than Mr C felt was reasonable, and he made further calls to the Scottish Ambulance Service (SAS) before it arrived. When Mr C complained to SAS about this, their …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2019
201809363 — Scottish Ambulance Service
A GP practice contacted the Scottish Ambulance Service (SAS) to request that C's grandchild (A) be transferred from a local hospital to a hospital with a paediatric unit after A became unwell with suspected meningitis. The practice prioritised the request as urgent, therefore requiring a response within an hour. SAS …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
201801934 — Scottish Ambulance Service
Ms C's brother (Mr A) collapsed at home and an ambulance was called. It took around 45 minutes to arrive and, upon arrival, the crew found Mr A to be in cardiac arrest. He was pronounced dead shortly after. Ms C complained about the failure to send assistance to Mr …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
202102932 — Scottish Ambulance Service
C’s elderly parent (A) had recently been discharged from hospital where they had been treated with antibiotics for a urinary tract infection. However, A continued to experience nausea and vomiting along with hallucinations and A’s GP requested an ambulance be provided for A within one hour. Although the Scottish Ambulance …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2023
NIPSO-201913310 — Belfast Health and Social Care Trust
We investigated a woman’s complaint that her father did not receive appropriate care in the Emergency Department of the Mater Hospital, Belfast. We found there were failures in his treatment, but that they did not ultimately lead to a deterioration in his health.
NIPSO (NI Public Service…
Health & Social Care
Oct 2021
PSOW-202006082 — Cardiff and Vale University Health Board
13. Mrs X complained about the Health Board’s refusal to remove a ‘Do not attempt cardiopulmonary resuscitation’ (DNACPR) form from her medical records. She explained that she felt worried, particularly if it became necessary for her to be readmitted into hospital. The Ombudsman found that the decision about the appropriateness …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-202000586 — Welsh Ambulance Services NHS Trust
Ms X complained on behalf of her late father, Mr Y, that the Welsh Ambulance Services NHS Trust(“WAST”) did not provide reasonable and timely care and treatment to Mr Y on 12December 2019. Ms X also complained that her complaint to WAST was not handled properly. The investigation found that …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
PSOW-202206255 — Cardiff and Vale University Health Board
Ms A complained about the treatment of her late sister, Mrs B, who contracted Covid-19 after being admitted to a hospital within the Health Board for an unrelated condition and sadly died. Ms A had received an initial complaint response under the Putting Things Right (“PTR”) process, but posed further …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202203473 — Cardiff and Vale University Health Board
Ms A complained about the treatment of her late sister, Mrs B, who contracted Covid-19 after being admitted to a hospital within the Health Board for an unrelated condition and sadly died. Ms A had received an initial complaint response under the Putting Things Right (“PTR”) process, but posed further …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202104936 — Cwm Taf Morgannwg University Health Board
Mrs A complained to the Ombudsman that when her mother, Mrs B was admitted to the Emergency Department (“the ED”) of the Princess of Wales Hospital (“the Hospital”), they had failed to assess and investigate her symptoms which were indicative of a stroke sufficiently quickly. She considered that this failure …
PSOW (Public Services Om…
Health
Upheld
Aug 2023
21-002-400 — Milton Keynes Council
Summary: Mr X complained about a lack of support from the Council with his homelessness, causing him distress. The Council was at fault for not properly communicating with him about COVID-19 vaccination programme. It has already apologised for the distress caused, which is an appropriate remedy. It was also at …
LGO (Local Government & …
Housing
Upheld
Feb 2022
21-007-453 — Birmingham City Council
Summary: There was no fault by the Council in its decision to suspend part of its pest control service during the COVID-19 pandemic. This was a decision it was entitled to take, and we have no grounds to question it. The Council’s handling of the complainant’s complaint was poor, but …
LGO (Local Government & …
Environment And Regulation
Upheld
Feb 2022
21-004-752 — Boutique Care Shepperton Ltd
Summary: Ms X complains about the care her mother, Mrs Y, received at The Burlington, a care home run by Boutique Care Shepperton Ltd. She says this resulted in having to move her mother and paying for two care homes. The Burlington’s actions contributed to the breakdown in relations between …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-000-364 — Essex County Council
Summary: Mr B complained the Council wrongly and repeatedly sent invoices to his mother, Mrs C, for care charges she did not owe, leading her to take her own life. We uphold the complaint, with the Council having acknowledged that it wrongly failed to identify Mrs C’s case as one …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-008-391 — Rossendale Borough Council
Summary: Mr X complained the Council wrongly refused his sporting club a COVID-19 grant on the basis that it is a members-only club and so not reasonably accessible to visiting members of the public. Mr X says this has caused financial hardship. The Council failed to give clear and consistent …
LGO (Local Government & …
Benefits And Tax
Upheld
Feb 2022
21-001-022 — Suffolk County Council
Summary: We upheld Miss X’s complaint about the Council’s failure to secure the provision in her daughter Y’s education, health and care plan. The Council agreed to apologise to Miss X and Y and make a payment to recognise Y’s lost provision.
LGO (Local Government & …
Education
Upheld
Feb 2022
21-015-900 — Birmingham City Council
The Council has apologised for the delay in responding to the complaint and we consider this is a suitable remedy.
LGO (Local Government & …
Other Categories
Upheld
Feb 2022
20-009-324 — London Borough of Bromley
Summary: We found fault with the Council’s handling of home to school transport arrangements for Ms X’s granddaughter, Y. The Council failed to ensure Y could use the transport she was eligible for free of charge. It will apologise to Ms X and reimburse the money she paid towards Y’s …
LGO (Local Government & …
Education
Upheld
Feb 2022
20-010-783 — Gloucestershire County Council
Summary: Mr S complained the Council and Trust failed to ensure his father, Mr F, was properly discharged from hospital into residential care. He also complained the Council failed to assess Mr F’s care and support needs. We have found fault in the actions of both organisations. We recommended financial …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-012-231 — Cornwall Council
Summary: Mrs X complains the Council has failed to meet her daughter’s assessed need to attend day services since they were allowed to reopen in 2020, which has caused her avoidable distress. The Council delayed in reviewing her daughter’s needs, then failed to review them properly and provided misleading and …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
20-014-148 — Stockport Metropolitan Borough Council
Summary: We have upheld complaints from Ms D, Ms K and Ms F about the actions of the Council, Home and Integrated Care Board in connection with the care of their late mother, Mrs M.
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-000-692 — Lancashire County Council
Summary: Ms X complains the Council failed to deal properly with her financial assessment by failing to respond to telephone communications and correspondence, and by failing to make reasonable adjustments to reflect her needs, resulting in it imposing charges which she could not afford to pay and taking 10 months …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
24-021-704 — Birmingham City Council
We cannot investigate Mr X’s complaint about missed refuse collections. This is because the issue stems from industrial strike action by the Council’s refuse collection crews and is a matter which affects all or most of the people in the Council’s area.
LGO (Local Government & …
Environment And Regulation
Apr 2025
25-001-182 — Birmingham City Council
Summary: We cannot investigate Mr X’s complaint about the Council’s failure to collect waste bins due to industrial action. We have no jurisdiction to investigate matters which affect all or most people in the Council’s area.
LGO (Local Government & …
Environment And Regulation
Apr 2025
24-023-429 — Birmingham City Council
Summary: We cannot investigate Mr X’s complaint about missed refuse collections. This is because the issue stems from industrial strike action by the Council’s refuse collection crews and is a matter which affects all or most of the people in the Council’s area
LGO (Local Government & …
Environment And Regulation
Apr 2025
25-000-442 — Birmingham City Council
Summary: We cannot investigate Mr X’s complaint about missed refuse collections. This is because the issue stems from industrial strike action by the Council’s refuse collection crews and is a matter which affects all or most of the people in the Council’s area.
LGO (Local Government & …
Environment And Regulation
May 2025
24-013-399b — Livewell Southwest (24 013 399b)
Summary: Mrs X complains about the way Plymouth County Council, Livewell Southwest and NHS Devon discharged her father, Mr Y, from hospital. We uphold her complaint. We found fault with the way Mr Y’s discharge was handled. As a result, Mrs X has experienced distress and uncertainty. The organisations have …
LGO (Local Government & …
Health
Upheld
Sep 2025
24-013-399a — NHS Devon ICB (24 013 399a)
Summary: Mrs X complains about the way Plymouth County Council, Livewell Southwest and NHS Devon discharged her father, Mr Y, from hospital. We uphold her complaint. We found fault with the way Mr Y’s discharge was handled. As a result, Mrs X has experienced distress and uncertainty. The organisations have …
LGO (Local Government & …
Health
Upheld
Sep 2025
201200363 — Business Stream
Mr C is the manager of business premises with over 100 staff, and where there is a call centre. He complained that Business Stream did not communicate clearly or provide timely advice about a planned shutdown of the water supply to the premises . The shutdown was to allow essential …
SPSO (Scottish Public Se…
Water
Upheld
Apr 2013
201507666 — Scottish Ambulance Service
Mr C complained about the time it took for the Scottish Ambulance Service to send an ambulance after he and his wife (Mrs C) were involved in a road traffic collision. It took 40 minutes for the ambulance to arrive and Mr C felt that the ambulance service should have …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2016
24-019-272 — Norwich City Council
Summary: Mr X complained the Council failed to provide him with interim accommodation when he became homeless. We found the Council at fault for this, causing Mr X significant injustice as he had to sleep rough. We are satisfied the Council has taken appropriate and positive steps towards improvements in …
LGO (Local Government & …
Housing
Upheld
Dec 2025
201904012 — Scottish Ambulance Service
C complained on behalf of their parent (A) after A was unwell and a GP made a home visit to assess them. The GP called for an ambulance for a 'within the hour' response. The ambulance service called back later and spoke with C to advise that the ambulance was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2021
PSOW-202006031 — Welsh Ambulance Services NHS Trust
Mrs X complained about the adequacy of the clinical assessment by a Community First Responder (“CFR”, a volunteer who is approved by the Trust to attend certain types of emergency calls in their local community) on 9 September 2020 when the CFR attended her father, Mr Y, following a 999 …
PSOW (Public Services Om…
Health
Not Upheld
Nov 2022
PSOW-202205762 — Swansea Bay University Health Board
Mr A complained that he was not informed of his positive COVID-19 test or provided with appropriate discharge advice about self-isoaltion. The Ombudsman was concerned that Swansea Bay University Health Board (“the Health Board”) could not satisfactorily evidence whether Mr A was informed about the positive test or provided with …
PSOW (Public Services Om…
Health
Mar 2023
PSOW-202207305 — Swansea Bay University Health Board
Mr A complained about whether the Health Board appropriately considered his mother’s case as part of its nosocomial review process (a process set up by Welsh Government for Health Boards to review cases where a patient may have contracted Covid-19 in hospital) and in line with the National Framework and …
PSOW (Public Services Om…
Health
Oct 2023
20-010-517a — Gloucestershire Clinical Commissioning Group (20 010 517a)
Summary: Mrs Y and Ms Z complained about funding for their mother, Mrs X’s, residential care and the response to an injury to Mrs X’s hand. We have upheld the complaints against the Council and recommended remedies. We have not upheld the complaint against the NHS Clinical Commissioning Group. The …
LGO (Local Government & …
Health
Not Upheld
Feb 2022
21-002-626 — Royal Borough of Windsor and Maidenhead Council
Summary: Mr B complained the Council refused to issue a refund after it cancelled the registrar service it was due to provide for his wedding. At this stage, the Ombudsman considers there was fault causing injustice because the Council failed to properly consider Mr B’s refund request. The Council should …
LGO (Local Government & …
Other Categories
Upheld
Feb 2022
21-003-087 — West Northamptonshire Council
Summary: Ms X complained the Council failed to ensure her son, Mr Z, received appropriate care, and also failed to complete his mental capacity assessment and care and support reassessment. The Council was not at fault in relation to these matters. However, it is at fault for delaying in making …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
Domestic Homicide Reviews(45)
Herefordshire — recommendation 5
Conduct an audit of completion of care plans, risk assessments and crisis contingency plans for the Herefordshire Memory Assessment Service and Older Person Services.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Cardiff — recommendation 15.1.3
That agencies should explore whether contingency plans can be put in place to mitigate the impact of a victim not being contactable by telephone.
Cardiff Metropolitan University of Wales | …
South Wales Police
Rotherham — recommendation 3
To review and address client services and needs during information communications technology downtime and responsible officer absences.
South Yorkshire Community Rehabilitation Company
Norfolk — recommendation 12
Mental Health Service contingency plans should take a ‘Think Family’ approach and be shared with related parties/carers having been written in plain English and avoiding professional jargon to ensure it is accessible to enable families and/or carers to fully understand the steps to take when required. This should include relevant …
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Croydon — recommendation 6.1.10.y
ACTION 2: Victim Support should ensure that services are resilient to pressures from restructure and resource limitations, and that business continuity plans are in place that account for IT failures, staff turnover and vacancy/absence cover, and that contact is prioritised in relation to risk as well as contact Service Level …
Victim Support
Stockport — recommendation 10
Pennine Care NHS Foundation Trust & Stockport Metropolitan Borough Council : should have triggers for responding to crisis calls and an escalation process in place
Pennine Care NHS Foundation Trust | …
Pennine Care NHS Foundation …
Lambeth — recommendation 1.6
The Trust reviews its physical communication systems at Community Team bases and puts in place contingency arrangements in case of failure.
South London & Maudesley NHS Foundation …
South London and Maudsley …
Somerset — recommendation 17.1.3
This agency to consider developing “Crisis, Relapse & Contingency Plans” with details of emergency contacts and useful advice to use in the event of serious distress. This has now been implemented and is operational.
Somerset Drug and Alcohol Service
Isle of Wight — recommendation 6.9
As a basic principle of emergency response, South Central Ambulance Service should work with Wightlink to ensure that there is a mutual understanding of how to access ferry terminals and that Wightlink reinforce their operating instructions that ensure that emergency services are called to the first available terminal and that …
South Central Ambulance Service | Wightlink
South Central Ambulance Service …
East Hertfordshire — recommendation 5.3.2
The MARAC Steering Group should review the MARAC process to ensure contingency planning is in place for individual cases.
MARAC Steering Group
West Cumbria — recommendation SAR9
Cumbria Safeguarding Adults Board to seek assurances that agencies creating contingency plans do so in a multi-agency forum and that the plans detail: the agencies involved and contact details, a detailed plan and arrangements for review, identified risks and risk management, and the process for escalation.
Cumbria Safeguarding Adults Board
Safeguarding Adults Board
Somerset — recommendation 2
The domestic abuse policy and procedure ‘Children Affected by Domestic Abuse – last updated in October 2014’ needs to develop guidance on safety planning, emergency planning including procedures for closing a case file, and good practice guidance.
Somerset Safeguarding Children Board
Haringey — recommendation 3
It is recommended that upon receipt of a court order and/or restraining order that ‘specified’ crime report be opened, the victim contacted and the following actions completed: (a) Contact the victim to gather and share information. (b) DASH (c) RARA (d) IDVA – referral to and working with to engage …
Hertfordshire Constabulary
Hertfordshire Constabulary
Haringey — recommendation 9
It is recommended that upon receipt of a court order and/or restraining order that ‘specified’ crime report be opened, the victim contacted and the following actions completed: (g) Contact the victim to gather and share information. (h) DASH (i) RARA (j) IDVA – referral to and working with to engage …
Metropolitan Police Service
Metropolitan Police Service
Haringey — recommendation R18
Before undertaking any significant reorganisation of services the Trust ensure that an assessment of risks arising out of the proposals is carried out and a means to implement a risk management plan to minimise any adverse outcomes identified.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Wiltshire — recommendation R40
For the team managing the RiO template documents to formally consider producing a new standard “Discharge to GP” editable letter in RiO that references a “Crisis and Contingency-type” plan. By AWP Clinical Systems Manager by 30 June 2016
Wiltshire Quality Director and Clinical Systems …
Norfolk — recommendation 7
All services providing care and/or home safety advice to vulnerable adults should include the promotion of the County Council’s assistive technology equipment which includes telephone call centre back-up for emergencies when a family member or carer cannot be contacted. This information must always be included where a pendant alarm is …
All services providing care and/or home …
Norfolk — recommendation 23
Contingency planning within care plans should also be shared as required with involved services and related parties/carers.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 21
The panel concluded that contingency planning should have been more robust with additional information related to this shared with the family. Contingency planning within care plans should also be shared as required with involved services and related parties/carers.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Norfolk — recommendation 9
All statutory, voluntary, or private services’ practitioners and carers whose role includes home safety advice and where a service user has or are intending to install privately purchased wi-fi enabled fire alarms, should strongly advise that at least two devices should be linked to the alarms to ensure back-up if …
All statutory, voluntary, or private services’ …
Norfolk — recommendation 8
Websites including the Norfolk County Council assisted technology site, the Fire & Rescue Service home safety site, and other county websites which give home safety advice, to insert a prominently displayed message, strongly advising that at least two people’s phones, tablets or similar devices should be linked to wi-fi enabled …
Norfolk County Council | Norfolk Fire …
Norfolk County Council
Norfolk — recommendation 7
All services providing care and/or home safety advice to vulnerable adults should include the promotion of the County Council’s assistive technology equipment which includes telephone call centre back-up for emergencies when a family member or carer cannot be contacted. This information must always be included where a pendant alarm is …
All Services
Norfolk — recommendation 6
That statutory regulations governing Smoke and Cabon Monoxide Alarms be amended to include the requirement that all internet enabled alarms must be linked to a minimum of 2 devices to ensure alerts can be acted upon at all times. Manufacturers must ensure the system cannot become operational until this is …
Department for Levelling Up, Housing & …
Ministry of Housing, Communities …
South Norfolk — recommendation 17.1
Norfolk County Council and Norfolk and Suffolk Foundation Trust to work with carers and their families to empower them by: providing guidance on how to stay safe and keep patients safe, plan for emergency situations, de-escalation techniques and the provision of resources
Norfolk County Council Adult Social Care …
Norfolk County Council- Adult …
North Lincolnshire — recommendation 8.8
Guidance to be formally issued to staff to ensure that in all cases where there are concerns regarding arson, that contact is made with Humberside Fire and Rescue where there is a change of address. This is particularly important where such cases do not fall under the remit of MAPPA.
National Probation Service
National Probation Service
Blackburn With Darwen — recommendation 3
The Ambulance Service review the risk assessment process undertaken in respect of their attendance at incidents, to establish whether it achieves the correct balance between the safety of their staff and the needs and welfare of the patient.
NHS Ambulance Trusts
Knowsley — recommendation 6.4
The oversight of the process of commissioning voluntary and independent organisations to provide services should be reviewed and, if necessary, strengthened in order to ensure that compliance with policy and procedure is consistent with the policies and procedures of the commissioning organisation and that where surges in demand place pressure …
Knowsley Community Safety Partnership
Northampton — recommendation 4
Procedure to be created for the call centre so when they take a call from someone saying they are at risk or unsafe in their property that all Team Leaders are emailed with the details, that the call is put through to the duty officer if available and if not …
Northampton Partnership Housing
Croydon — recommendation 7
Address the issue of having a formal commissioned system in place to provide Appropriate Adult services out of hours.
Croydon Community Safety Partnership
Northumberland — recommendation 1 (sub-point)
The NSCB will review and revise the early help procedures and guidance to include the following key elements: The threshold for undertaking an Early Help Assessment; to include an escalation policy, for all professionals, linked to the updated multi-agency Thresholds Document. The escalation policy should cover the opening, stepping up/down …
Northumberland Safeguarding Children Board
Northumberland — recommendation 10
To ensure that appropriate training is available and the systems for escalation are understood.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Cheltenham — recommendation GASC.5
ASC workers to clearly record the purpose and anticipated content of ongoing welfare telephone calls and/or visits and where for any reason the welfare check is not undertaken, this is immediately escalated to the line manager for discussion and agreement on next steps. ASC workers may wish to agree in …
Gloucestershire Adult Social Care
Sefton — recommendation 9
Staff must follow and implement the Protocol for the Missing Patient (CLIN CORP 76) Risk Assessments must be completed The Protocol for the Missing Patient (CLIN CORP 76) is implemented and followed / reviewed and includes the suggested Contract and Risk Assessments
Southport and Ormskirk Hospitals NHS Trust
Sefton — recommendation 2
Policy will be fit for purpose – to include MARAC processes/ staffs duties/ Threats to kill/ knife crime –MARAC to be included within Safeguarding Training A protocol will be devised for the AAR team and A&E as to what steps should be taken following a patient being discussed at MARAC. …
Southport and Ormskirk Hospitals NHS Trust
Chiltern — recommendation Panel Recommendation
SCAS to review the Service guidance on requesting Police attendance for 999 calls where there is a concern about safety of staff or violence is possible.
SCAS
South Central Ambulance Service …
South Ribble — recommendation None
Safety of practitioners when lone working.
Chorley and South Ribble ICB
Rochdale — recommendation 2
Review the drafted amendments to the Responsive Repairs Policy version 0.9 and seek to understand if this can be implemented. This policy states in section 5 “…..Where exceptional circumstances occur which pose an immediate health and safety risk we will aim to attend within four hours…”
The Guinness Partnership
Guinness Partnership
East Sussex — recommendation 12
That the council ensures that all work to be carried out because of domestic abuse is carried out as an emergency or within an agreed timescale.
Lewes District Council – Tenancy Services …
Lincoln — recommendation 3
Complete an Internal Review of this case to explore learning and wider themes and trends which may include risk assessment of closing cases and contingency planning.
Lincolnshire County Council Adult Social Care …
Lincolnshire County Council
Cwm Taf — recommendation 6
The Health Board and Local Authorities should be asked to review policies and procedures in relation to risk assessments, risk management and contingency planning and undertake audit work to ensure that the correct procedures are being followed
The Health Board | Local Authorities
Local Authorities
Cwm Taf — recommendation 5
The Health Board and Local Authorities to provide assurances that there is adequate training in risk assessment/ risk management and contingency planning for all mental health practitioners.
The Health Board | Local Authorities
Local Authorities
Stockport — recommendation 1
Pennine Care NHS Foundation Trust : should ensure that the quality of care and contingency plans is audited, including the checking of plans against identified needs
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Lancaster — recommendation 7
Consider whether the Blue Light 71 needs to be revised to ensure risks and vulnerabilities are understood.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Blackburn With Darwen — recommendation 2
Northwest Ambulance Service Trust To review their policy/procedure/training in respect of directing members of the public to examine patients in situations such as the one subject of this review, to ensure that consideration is given to the vulnerability of the person being directed.
Northwest Ambulance Service Trust
North West Ambulance Service …
Salford — recommendation 7a
Understand when abuse and / or neglect may result in the need to consider urgent interventions such as a change of accommodation,
Community Safety Partnership | Salford Safeguarding …
Safeguarding Adults Board
CJINI inspection reports(3)
A review of the criminal justice system’s preparedness for exceptional or prolonged public disorder
Governance, The Criminal Justice System
Jun 2013
An Inspection Of Public Protection Arrangements Northern Ireland
Risk Management and public protection arrangements, Probati…
Jun 2011
An inspection of Public Protection Arrangements Northern Ireland
Risk Management and public protection arrangements, Probati…
Jun 2011
DSA service inquiries(25)
Service Inquiry report into the Loss of Watchkeeper (WK043) Unmanned Air Vehicle over Cardigan Bay in West Wales on 24 March 2017
The Service Inquiry report into the loss of Watchkeeper (WK043) unmanned air vehicle over Cardigan Bay in West Wales on 24 March 2017.
Aviation
Apr 2019
Service Inquiry report into the Loss of Watchkeeper (WK042) Unmanned Air Vehicle over Cardigan Bay in West Wales on 3 February 2017
The Service Inquiry report into the loss of Watchkeeper (WK042) unmanned air vehicle over Cardigan Bay in West Wales on 3 February 2017.
Aviation
Apr 2019
Service Inquiry into the accident involving HAWK T Mk1A XX204 on 20 March 2018
A service inquiry report into the accident involving HAWK T Mk1A XX204 on 20 March 2018.
Aviation
Oct 2019
Service Inquiry into the death of a soldier from a gunshot wound at Camp Taji, Iraq on 2 January 2017
Service Inquiry into the death of a soldier from a gunshot wound at Camp Taji, Iraq on 2 January 2017.
Weapons & Ordnance
Nov 2019
Service Inquiry into the death of a soldier following an animal attack at Liwonde National Park, Malawi on 5 May 2019
Service Inquiry into the death of a soldier following an animal attack at Liwonde National Park, Malawi on 5 May 2019.
Other
Oct 2020
Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area
The Service Inquiry report into the death of a soldier of the Scottish and Northern Irish Yeomanry during an accident involving a Jackal vehicle on Catterick training area on 29 January 2019.
Land
Jan 2021
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood on 16 November 2020
Maritime
Mar 2022
Service Inquiry into the Loss of Hawk T Mk1 XX189 from 736 Naval Air Squadron, RNAS Culdrose
Service Inquiry into the loss of a Hawk T1 of 736 Naval Air Squadron from RNAS Culdrose; both aircrew ejected and the aircraft was destroyed.
Aviation
Jul 2022
Service Inquiry investigating the accident involving F-35B ZM152 on HMS Queen Elizabeth on 17 November 2021 - Interim Report
Interim Report from the Service Inquiry investigating the accident involving F-35B ZM152 on HMS Queen Elizabeth on 17 November 2021.
Aviation
Sep 2022
Service Inquiry into the loss of F-35B Lightning ZM152 (BK-18)
Service Inquiry into the loss of an F-35B Lightning of 617 Squadron, embarked on HMS Queen Elizabeth, which crashed into the Mediterranean during take-off; the pilot ejected safely.
Aviation
Aug 2023
Service Inquiry into the fatal accident involving a Scimitar Fighting Vehicle on Salisbury Plain Training Area - 15 October 2021
Service Inquiry into the fatal accident involving a Scimitar Fighting Vehicle on Salisbury Plain Training Area - 15 October 2021.
Land
Nov 2023
Service Inquiry into the death of a soldier from 23 Parachute Engineer Regiment at MOD Woodbridge, July 2022
Service Inquiry report into the death of a soldier from 23 Parachute Engineer Regiment at MOD Woodbridge in July 2022.
Aviation
Feb 2024
Service Inquiry into the death of a service person during an adventurous training expedition to Stubai Glacier, Austria on 11 March 2023
The Service Inquiry report into the death of a service person during an adventurous training expedition to Stubai Glacier, Austria on 11 March 2023.
Land
Mar 2025
Service Inquiry into death of a Royal Marine during an endurance march on Dartmoor Training Area on 28 May 2015
The Service Inquiry report into the death of a Royal Marine while conducting officer training at Commando Training Centre, Royal Marines Lympstone.
Land
Mar 2016
Service Inquiry into the Watchkeeper (WK031) Unmanned Air Vehicle (UAV) accident at West Wales Airport on 16 October 2014
The report of the Service Inquiry following the Watchkeeper (WK031) Unmanned Air Vehicle (UAV) accident at West Wales Airport.
Aviation
Aug 2016
Service Inquiry into the Watchkeeper (WK006) Unmanned Air Vehicle (UAV) accident at Boscombe Down Aerodrome on 2 November 2015
The report of the Service Inquiry following the Watchkeeper (WK006) Unmanned Air Vehicle (UAV) accident at Boscombe Down Aerodrome.
Aviation
Dec 2016
Service Inquiry into an accident involving a Puma HC MK 2 (XW229) in Kabul, Afghanistan on 11 October 2015
Service Inquiry into the Puma HC Mk2 accident at Headquarters Resolute Support, Kabul, in which five people died when the aircraft struck a tethered surveillance balloon cable on approach.
Aviation
Dec 2016
Service Inquiry into the aircraft accident involving YAK52 G-YAKB on 8 July 2016
The report of the Service Inquiry following the YAK52 G-YAKB aircraft accident close to Boscombe Down, Wiltshire
Aviation
Jun 2017
Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013
The releasable extracts of the Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013.
Land
Apr 2017
Service Inquiry into the death of a soldier participating in live fire tactical training at Heely Dodd Range, Otterburn on 22 August 2016
The report of the Service Inquiry following the death of a soldier participating in live fire tactical training at Heely Dodd Range, Otterburn on 22 August 2016.
Other
Nov 2017
Service Inquiry report into the Challenger 2 incident at Castlemartin Ranges, Pembrokeshire on 14 June 2017
The Service Inquiry report into the Challenger 2 incident at Castlemartin Ranges, Pembrokeshire on 14 June 2017.
Other
Jul 2018
Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area on 1 November 2016.
The Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area on 1 November 2016.
Weapons & Ordnance
Aug 2018
Service Inquiry into the alleged exposure of UK Defence Personnel to asbestos during overseas exercises and training since 2018
Service Inquiry into the alleged exposure of UK Defence Personnel to asbestos during overseas exercises and training since 2018.
Land
Aug 2022
Service Inquiry into the accident involving Red Arrows Hawk T Mk1 XX179 near Bournemouth
Service Inquiry into the death of Red Arrows pilot Flight Lieutenant Jon Egging, whose Hawk T1 crashed near Bournemouth following a display.
Aviation
Dec 2012
Service Inquiry into the accident involving Hawk T Mk1 XX177 at RAF Scampton
Service Inquiry into the death of Red Arrows pilot Flight Lieutenant Sean Cunningham, who was fatally injured when his ejection seat initiated while the Hawk T1 was stationary at RAF Scampton and the main parachute did not deploy.
Aviation
Feb 2014
ISC reports(7)
Inquiry into Intelligence, Assessments and Advice prior to the Terrorist Bombings on Bali 12 October 2002
Special Report
Dec 2002
Report into the London Terrorist Attacks on 7 July 2005
Special Report
May 2006
Review of the Intelligence on the London Terrorist Attacks on 7 July 2005
Special Report
May 2009
The 2017 Attacks: what needs to change?
Inquiry into the five terrorist attacks in the UK in 2017 and the lessons for the intelligence agencies and police.
Special Report
Nov 2018
Northern Ireland-related terrorism
Inquiry into the threat from Northern Ireland related terrorism and the work of the intelligence agencies in addressing it.
Special Report
Oct 2020
Extreme Right-Wing Terrorism
Inquiry into the threat from extreme right-wing terrorism in the UK and the response of the intelligence community.
Special Report
Jul 2022
Report on the intelligence relating to the murder of Fusilier Lee Rigby
Inquiry into the intelligence agencies' handling of the two individuals responsible for the murder of Fusilier Lee Rigby in 2013.
Special Report
Nov 2014