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 19 independent accountability sources, so the source mix matters as much as the headline total.
244 inquiry recs
159 PFD reports
719 committee recs
32 HSSIB recs
69 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
7 Scottish FAIs
3 Article 2 learning points
10 detention investigation recs
29 PHSO decisions
80 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(244)— showing 50 strongest matches
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 response published by this government.
Unknown
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 response published by this government.
Unknown
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 response published by this government.
Unknown
COVID-M5.6 — Blueprints for Critical Care Medical Technology
Recommendation: The UK government and devolved administrations should jointly commission a group of experts to develop blueprints for rapidly scalable critical care medical technology, aligned with the range and severity of pandemic risks identified in the National Security Risk Assessment, within …
Gov response: No formal response published by this government.
Unknown
COVID-M5.5 — Emergency Healthcare Equipment Plan
Recommendation: UK regulators, including the Health and Safety Executive, the Health and Safety Executive for Northern Ireland, the Office for Product Safety and Standards and the Medicines and Healthcare products Regulatory Agency, should establish an emergency healthcare equipment cross-regulator plan for …
Gov response: No formal response published by this government.
Unknown
COVID-M5.4 — Emergency Healthcare Equipment Regulations
Recommendation: The UK government and devolved administrations should publish simplified regulations for emergency healthcare equipment that are aligned with and cover the range and severity of pandemic risks identified in the National Security Risk Assessment. The simplified regulations should: establish the …
Gov response: No formal response published by this government.
Unknown
COVID-M5.3 — Emergency Procurement and Distribution Systems
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, within 12 months of the publication of this Report, should each have ready systems for the emergency procurement and distribution of healthcare equipment. These new systems must: integrate procurement …
Gov response: No formal response published by this government.
Unknown
COVID-M5.2 — Pandemic Exercises to Include Emergency Procurement
Recommendation: The UK government and devolved administrations should evaluate the readiness of the structures, systems and processes for the emergency procurement and distribution of healthcare equipment as part of UK-wide pandemic response exercises.
Gov response: No formal response published by this government.
Unknown
COVID-M5.1 — Pandemic Stockpile Composition and Inspection
Recommendation: The UK government and devolved administrations should ensure, within 12 months of the publication of this Report, that the pandemic stockpiles: retain stock that is better aligned with the range and severity of pandemic risks identified in the National Security …
Gov response: No formal response published by this government.
Unknown
COVID-M3.7 — ICU Resource Allocation Framework
Recommendation: The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic. That framework must: …
Gov response: No formal response published by this government.
Unknown
COVID-M3.6 — Scale Up Hospital Capacity
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic plans include practical steps to rapidly scale up hospital capacity to treat acutely unwell patients. This should include …
Gov response: No formal response published by this government.
Unknown
COVID-M3.5 — Scale Up Urgent and Emergency Care
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic. Plans must ensure that there is sufficient workforce …
Gov response: No formal response published by this government.
Unknown
COVID-M3.2 — Visiting Restrictions Guidance
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should publish guidance for the implementation of visiting restrictions in hospitals in the event of a future pandemic. The guidance should identify the circumstances in which visiting restrictions should …
Gov response: No formal response published by this government.
Unknown
FENN-88 — Conduct biannual joint emergency services exercises involving staff and public
Recommendation: There shall be a joint exercise with the emergency services at least twice each year. London Underground must involve as many different fire stations, staff and members of the public as possible.
Unknown
FENN-12 — Include evacuation by train within all station emergency evacuation plans.
Recommendation: Station evacuation plans should include evacuation by train.
Unknown
FENN-9 — Agree station emergency instructions with LFB for staff training
Recommendation: Station instructions for emergencies and closure must be agreed with the London Fire Brigade and used in training station staff.
Unknown
HIDD-87 — Develop and regularly exercise effective emergency plans for all station staff
Recommendation: BR shall ensure that each area manager, station manager and all senior station staff have an effective emergency plan for their area that is understood by all their staff and is the subject of regular exercises.
Unknown
HIDD-82 — BR to review and test communication systems with emergency services weekly
Recommendation: BR shall review its communication systems with the emergency services to ensure that efficient methods exist to provide and disseminate early information requiring immediate action. In the course of the review BR shall look particularly at communication between signal boxes …
Unknown
HIDD-81 — BR to equip signal boxes with direct lines and emergency dialling systems
Recommendation: BR shall complete its programme of equipping major signal boxes with direct lines to the appropriate electrical control and equipping other signal boxes with priority emergency dialling systems. Those direct lines and emergency dialling systems shall be logged and tested …
Unknown
HIDD-79 — Department of Health to review Circular 71, clarifying Major Incident declaration terms
Recommendation: The Department of Health shall review DHSS Circular 71 in consultation with emergency and medical services to reflect all lessons learned but in particular in relation to procedures for declaring a Major Incident. The Department of Health shall specifically require …
Unknown
HIDD-76 — Require BR and emergency services to maintain joint planning with table-top exercises
Recommendation: In the exercise of command and control at accident sites BR and the emergency services shall maintain their policy of joint planning supported by table-top exercises.
Unknown
HIDD-74 — Require emergency services to recognise Civil Police primacy in non-fire accidents
Recommendation: The emergency services shall recognise the primacy of the Civil Police authority in accidents of this kind where there is no fire. This recognition does not preclude delegation to the LFB of control at trackside.
Unknown
P1-44 — Investigate LFB-MPS-LAS system compatibility
Recommendation: Steps be taken to investigate the compatibility of the LFB systems with those of the MPS and the LAS with a view to enabling all three emergency services' systems to read each other's messages.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-43 — Use METHANE messages for Major Incidents
Recommendation: A 'METHANE' (Major incident declared, Exact location, Type of incident, Hazards, Access, Number and type of casualties, Emergency services present and required) message should be sent as soon as possible by the emergency service declaring a Major Incident.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-42 — Designate single point of contact in control rooms
Recommendation: A single point of contact should be designated within each control room to facilitate such communication.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-41 — Establish inter-service control room communications
Recommendation: On the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
P1-40 — Communicate Major Incident declarations to all responders
Recommendation: Each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible.
Gov response: The government accepted in principle all Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to new duties on building owners …
Accepted
MAI-157 — Review stretcher availability for mass casualties
Recommendation: The Home Office, the Department of Health and Social Care, the Department for Transport and the Department for Levelling Up, Housing and Communities should conduct a review to ensure that stretchers that are appropriate in design and adequate in numbers …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-130 — Public Access Trauma kit availability
Recommendation: The Home Office and the Department of Health and Social Care should consider how to ensure Public Access Trauma kits are available in all locations where they are most likely to be needed.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-107 — Ensure immediate HART resource deployment
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should develop procedures to ensure that, so far as possible, each ambulance service trust is able to deploy or call upon HART resources immediately in the event …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-47 — Sufficient resources for operational planning
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should work together to put in place robust systems, policies and guidance to ensure that all police services have sufficient resources dedicated …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-46 — Guidance on Major Incident plan review frequency
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should issue guidance for all police services on how often operational plans for responding to a Major Incident, including a terrorist incident, …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-44 — Ambulance trusts submit resource recommendations
Recommendation: Having carried out that review, the trusts should make recommendations to their NHS commissioners about the additional and/or different resources they require in order to ensure that they are able to respond effectively to a mass casualty incident in the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-42 — SMG sharing of emergency response plans
Recommendation: SMG should review its processes to ensure that it shares with Greater Manchester Police, Greater Manchester Fire and Rescue Service, British Transport Police and North West Ambulance Service its most current emergency response plans and policies for dealing with an …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
COVID-M5.10 — Transparency, Governance and Accountability in Emergencies
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should improve transparency, governance and accountability for procurement in an emergency. As a minimum, these improvements should include the following: Enhancing transparency Any central digital platform used for procurement …
Gov response: No formal response published by this government.
Unknown
COVID-M5.8 — Training in Emergency Procurement and Distribution
Recommendation: The UK government and devolved administrations should each establish a pool of officials who are trained in the emergency procurement and distribution of healthcare equipment. Completion of the training should be mandatory for at least 20% of the workforce of …
Gov response: No formal response published by this government.
Unknown
SP9 — NWAS Major Incident declaration procedures
Recommendation: North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how declarations are made and how they are communicated internally and to other emergency services.
Gov response: DHSC and NHS England support the issues that the recommendations for the North West Ambulance Service (NWAS) are directed towards. However, while NHS England considers local review of procedures and terminology to be important and …
Accepted
TAYL-F63 — Brief entrance police on emergency service plans and deployment information
Recommendation: Police officers posted at the entrances to the ground should be briefed as to the contingency plans for the arrival of emergency services and should be informed when such services are called as to where and why they are required.
Unknown
TAYL-F62 — Review emergency vehicle access, rendezvous points, and internal ground accessibility
Recommendation: Contingency plans for the arrival at each designated sports ground of emergency vehicles from all three services should be reviewed. They should include routes of access, rendezvous points, and accessibility within the ground itself.
Unknown
FENN-152 — Consider national disaster planning desk for experience and emergency coordination
Recommendation: Consideration should be given to a national disaster planning desk where the experience gained from disasters and their investigation and civil emergencies can be retained. Advice on the coordination of individual emergency plans should also be available at a national …
Unknown
FENN-119 — Improve London Fire Brigade radio communications for firefighters operating below ground.
Recommendation: The London Fire Brigade must improve the means of radio communications between fire-fighters below ground.
Unknown
FENN-118 — Provide public address equipment on all trains for crew and controller use.
Recommendation: There shall be public address equipment on all trains for use by the crew and the line controller.
Unknown
FENN-116 — Issue radios to station staff and ensure compatibility with tunnel equipment.
Recommendation: Station staff shall be issued with radios. Station radio equipment shall be made compatible with that used in the running tunnels.
Unknown
FENN-115 — Clearly mark station telephones, PA controls, and expand public payphone provision.
Recommendation: Platform and kiosk telephones, together with controls for public address equipment, must be clearly marked. At all telephone points there should be a list of key telephone numbers. An aide memoire of important telephone numbers should be issued to London …
Unknown
FENN-111 — Ensure British Transport Police and Fire Brigade radio compatibility in underground stations.
Recommendation: The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire Brigade.
Unknown
FENN-48 — Fit locked emergency gates with alarmed panic bars
Recommendation: Locked emergency gates shall be fitted with alarmed panic bars.
Unknown
FENN-13 — Regularly test water fog equipment and train staff in its use.
Recommendation: Water fog equipment must be regularly tested and staff trained in its use.
Unknown
FENN-11 — Agree and mark emergency services rendezvous and staff assembly points at stations.
Recommendation: A rendezvous point for the emergency services and a staff assembly point at each station must be agreed and marked.
Unknown
POPP-A.12 — Amend Green Guide for comprehensive steward training and instruction on emergencies.
Recommendation: The Green Guide should be amended to contain a specific provision, in relation to stewards, (i) that they should be trained and instructed to deal with any emergency relating to fire or evacuation (see also Recommendations 7 and 10); (ii) …
Unknown
POPP-A.11 — Amend Green Guide to require manned, openable exit gates during public use.
Recommendation: Paragraphs 6.14.6 of the Green Guide should be amended to read: “All exit gates should be manned at all times while the ground is used by the public and be capable of being opened immediately from inside by anyone in …
Unknown
Prevention of Future Deaths reports(159)— showing 50 strongest matches
Jessica Ashton-Pyatt
Concerns: The emergency response was uncoordinated, lacked consultant leadership, and critical equipment like the defibrillator was uncharged with missing pads, compromising immediate patient care.
Overdue
David Selman
Concerns: An ambulance delay resulted from a crew misunderstanding a 'stand down' order and crucial updated patient information not being relayed. This prevented appropriate paramedic deployment.
Overdue
Janet Richardson
Concerns: The deceased fell into the sea during a rescue medical evacuation.
Response (Cruise Maritime Services International Limited): CMSI states that they strongly believe that the Norwegian Rescue Service had appropriate procedures in place. However, they changed their procedures following the incident to prevent similar incidents from recurring, …
Response (Newmarket Promotions Ltd): Newmarket Promotions Ltd. states that they forwarded the Coroner's recommendations to their clients, however, disclaim responsibility as emergency procedures are the responsibility of the authorities.
Overdue
Andrew Phrydas
Concerns: London Underground lacked a process for simultaneous dual-line shutdown at intersecting stations and failed to alert the train driver directly and effectively when a person was on the track.
Overdue
Dr Edward Slaney
Concerns: There is a lack of established criteria and guidance for planning authorities to assess the wind effects of tall buildings on the safety of all highway users.
Overdue
Umul Audu
Concerns: The lack of transport heater availability during patient transfers risks future patients suffering hypothermia, potentially leading to death.
Response (University College London Hospitals NHS Foundation Trust): University College London Hospitals NHS Foundation Trust acknowledges the concerns about the lack of a transport heater, but argues against changing its policy and introducing transport heaters. They believe standard …
Responded
Amy Friar
Concerns: The absence of universal emergency codes across the prison estate creates confusion for transferring staff, risking delays in emergency response.
Overdue
Marco Lima De Araujo
Concerns: There is no formal protocol for reporting and coordinating rescue efforts during life-threatening incidents in Portsmouth Harbour.
Response (Maritime Coastguard Agency): The Maritime Coastguard Agency outlines its existing protocols for maritime search and rescue, including communication and cooperation with the Queen's Harbour Master Portsmouth and participation in the SOLFIRE multi-agency response …
Responded
Janette Sutherland
Concerns: A drainage channel and concrete headwall present a significant hazard to road users. A safety barrier is needed to prevent vehicles from impacting the headwall.
Response (Caerphilly County Council): The council will investigate the site of the incident to provide recommendations for measures to alleviate future incidents. A Road Restraint Risk Assessment Process (RRRAP) survey was carried out on …
Response (Caerphilly County Council): Following a Road Restraint Risk Assessment Process (RRRAP), the council will demolish a headwall and re-profile the surrounding ditch, with works programmed for commencement in July.
Responded
Christopher Williams
Concerns: A critical defibrillator failed due to lack of daily checks and no cross-check system. The hospital also lacked a policy for managing sudden or unexpected deaths.
Overdue
M5 (Seven)
Concerns: A firework display adjacent to the M5 caused greatly reduced visibility and a fatal multi-vehicle collision, highlighting a lack of preventative measures for such events.
Overdue
Joan Richardson
Concerns: The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.
Response (Leeds West Clinical Commissioning Group): The CCG will send a letter to all GP practices reiterating their obligations regarding safe medical cover during training sessions and emphasizing the need for clear communication regarding access to …
Overdue
Julie Robertson
Concerns: Delayed blood availability due to the lack of a ward blood fridge and consistently poor record-keeping, with staff unaware of good practice, impacted patient care and readiness for surgery.
Overdue
Edna Smither
Concerns: Inadequate staff First Aid training, a locked emergency exit, and a lack of calm leadership during an emergency were compounded by significant delays in reporting serious incidents under RIDDOR.
Overdue
Rosalind Adshead
Concerns: A severely ill patient was unsafely transferred between hospitals in the early hours, a practice deemed unsafe by consultants, exacerbated by ambulance shortages.
Overdue
Sapper Dylan Gibson
Concerns: The absence of master keys in the guard room for all camp buildings prevents prompt access in emergencies, potentially delaying critical interventions.
Response (Ministry of Defence): Sapper Gibson's unit now holds keys to all buildings and rooms in the guardroom. The MOD is updating its Health and Safety risk assessment guidance to ensure site risk assessments …
Responded
Sandra Danks
Concerns: An electricity supply interruption to the main oxygen apparatus stopped oxygen provision, as there was no backup system in place to continue oxygen delivery.
Response (BOC Healthcare): BOC states they followed all procedures and contractual obligations, and all equipment was in working order. They see no reason to take further action but will monitor procedures.
Overdue
Peter Mackie
Concerns: Inadequate numbers of first aiders and healthcare staff were available across prison sites, compounded by a lack of clear guidance for staff on when and how to commence CPR.
Response (HM Prison and Probation Service): HMP Grendon and Springhill are working to increase the number of trained first aid staff, a new risk assessment will be completed to ensure appropriate levels of staff are identified …
Responded
Garry Gilbey
Concerns: The prison lacked a clear policy for calling ambulances or defining medical emergencies, leading to inadequate staff training for night-time assessments and inconsistent recording of critical healthcare information.
Response (Department of Health): The Department of Health provides context regarding healthcare contracts for prisons being performance managed by NHS England's Area Teams, and refers to DH and NOMS guidance issued in 2011 regarding …
Response (HM Prison and Probation Service): Since the death, Prison Service Instruction 2013/03 Emergency Response Codes has been issued, reminding staff who can call a medical emergency and providing guidance on the use of medical emergency …
Responded
Noreen Porter
Concerns: Care home staff failed to perform CPR, indicating a complete absence of processes or procedures for emergency resuscitation.
Response (Bupa): Bupa acknowledges that CPR was not carried out when it should have been. Following the incident, Ardenlea Grove Nursing Home has reappraised procedures and processes for life support, and has …
Responded
Lana-Liza Chervonenko
Concerns: High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Overdue
Andrea Thirkell
Concerns: Lack of formal monitoring for patients awaiting discharge and an absence of clear policy for safe late-night discharges risk inconsistent, potentially erroneous decisions by medical staff.
Overdue
Davina Tavener
Concerns: Current aviation regulations fail to mandate critical medical equipment like defibrillators and airway adjuncts on aircraft, significantly reducing a passenger's chance of survival during in-flight cardiac arrest despite such equipment being available and simple to operate.
Response (IAA): The IAA notes the current practices of Irish air operators regarding AEDs and aircraft, and states that the Chief Executive of the IAA has written to the Chief Executive of …
Response (EASA): EASA acknowledges the concerns and will engage with Member States to reconsider the situation through analysis of available data, launching a first discussion at the next meeting with air operations …
Response (CAA): The CAA will raise the issue of mandatory medical equipment on aircraft, including defibrillators, at the Flight Operations Liaison Group, to obtain an industry view and assess whether operators should …
Responded
Kenneth Bailey
Concerns: Limited manning hours at a local fire station caused delayed emergency response times, which encouraged untrained neighbours to undertake dangerous rescues, increasing their risk of injury or death.
Response (Greater Manchester Fire and Rescue Service): Greater Manchester Fire and Rescue Service is undertaking internal and external recruitment to establish a new duty system at Mossley Fire Station, expected to be in place by November 2015. …
Responded
Stanley Oliver
Concerns: The hospital lacked an official on-call rota and actual provision for GI Radiologists to perform critical procedures out of hours, particularly on weekends, despite identifying this as a risk.
Response (S Oliver): Salford Royal NHS Foundation Trust plans to develop a 7-day consultant-level non-vascular intervention rota by April 2016. In the short term they will use an ad hoc service with support …
Response (Department of Health): The Department of Health commissioned the Centre for Workforce Intelligence to gather evidence on possible shortage occupations, leading to radiologists being added to the Shortage Occupation List in April 2015. …
Responded
Thelma Jones
Concerns: The provided text only states the report concerns the Acute Medical Unit (AMU) where the deceased was admitted, without specifying the issues or failures.
Response (Brighton and Sussex University Hospitals NHS Trust): The Trust believes that the medical notes contain appropriate detailed information on the care and treatment given within AMU and in relation to the NEWS scores, therefore remedial action is …
Responded
Dennis Stark
Concerns: A rehabilitation unit's lack of a lift significantly delayed the emergency removal of an obese patient from a second-floor room, posing a risk of future deaths for individuals requiring urgent medical attention.
Overdue
Christine McNamara
Concerns: There is a lack of clear pathways for post-ERCP patients with complications, and out-of-hours radiography is hampered by the absence of a Maidstone surgical consultant for urgent referrals.
Response (Maidstone and Tunbridge Wells NHS Trust): The trust implemented a new pathway in January 2016 for managing patients who develop post-endoscopic surgery complications, with a review scheduled for October 2016.
Responded
Jasmine Lapsley
Concerns: Emergency services in rural NW Wales suffer from a lack of nighttime air support, ineffective rostering and communication for Community First Responders, and inadequate resource planning for seasonal population increases.
Response (Welsh Government): The Welsh Air Ambulance is expanding by an additional helicopter in July 2016 and has funding for three more in early 2017. The Welsh Ambulance Services NHS Trust has piloted …
Response (Welsh Ambulance Service NHS Trust): This response is not classifiable due to being unreadable.
Responded
Arthur Mason
Concerns: Staff lacked formal risk assessment training and failed to identify risks for farm tasks, compounded by the absence of a comprehensive emergency plan for hazardous areas.
Response (Maurice Mason Ltd): The company has ceased the practice of personnel entering grain bins for cleaning. They have also booked IOSH Directing Safely and Managing Safely courses for staff.
Responded
Ronald Hamer
Concerns: An ambulance response was critically delayed by over two hours, and no follow-up calls were made to the patient's family. This was attributed to an absence of clear planning for high call volumes, risking future service failures.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Services NHS Trust has developed an action plan and is monitoring progress through a Task and Finish Group of senior staff, led by the Director of Quality, …
Overdue
John Crittall
Concerns: An acutely unwell patient was admitted to a private hospital lacking HDU/ITU facilities and emergency protocols. Chest drain insertion was performed against guidelines, without appropriate imaging or confirmation of its position, delaying critical haemothorax management.
Response (Royal College of Radiologists): The Royal College of Radiologists will make its Fellows and members aware of the British Thoracic Society Pleural Disease Guidelines 2010.
Response (Mount Alvernia Hospital): Following concerns about admitting acutely unwell patients without HDU/ITU facilities, BMI Mount Alvernia Hospital updated its admission policy to ensure all patients meet admission criteria. They also introduced mandatory training …
Responded
Christopher Sears
Concerns: Bus drivers transporting students are not required to have Basic Life Support training or emergency protocols, and BLS is not routinely taught in secondary education.
Response (Department for Transport): The DfT will reinforce the importance of basic life support training for drivers through targeted communications and social media, and raise the profile of the issue with bus industry and …
Response (Department for Education): The DfE intends to consult on a revised version of guidance on school transport in the autumn and will consider whether they should further clarify the description of the training …
Responded
Miles Abel
Concerns: The procedure for GPs to refer patients to the Community Mental Health Team lacked an audit trail to confirm faxes were sent, and follow-up phone calls were not always made.
Response (The Endless Street Doctors Surgery): The Endless Street Doctors' Surgery has implemented a new Standard Operating Procedure for urgent faxes. This includes a fax log, scanning a dated 'faxed' stamp into patient notes, and requiring …
Response (Department of Health): The Department of Health acknowledges the local issue with faxed referrals and notes that the Endless Street Surgery has implemented a strengthened system. They highlight broader government initiatives for digitising …
Responded
Imad Hassan
Concerns: There is no formal backup plan for PCI procedures when primary hospitals lack capacity, and no agreed pathways for accessing critical care beds outside Wales or for unconscious STEMI patients.
Response (Hassan): Cwm Taf University Health Board has been working to develop an interim solution pending the completion of a comprehensive pathway in the summer of 2017. A local corrective Action Plan …
Response (Imad Hassan): The United Hospitals University Bristol Trust will accept patients if there is insufficient critical care capacity in South Wales, facilitated by the regional PPCI centre. Work is underway on an …
Overdue
Jane Reason
Concerns: There is a critical shortage of public access defibrillators in colleges and schools, and a need for increased public education on their placement and effective use during cardiac arrest.
Response (Department for Education): The Department for Education published guidance on automated external defibrillators in April 2016 and has since published new guidance relevant to further education colleges. They will also write to the …
Response (Resuscitation Council UK): The Resuscitation Council UK promotes CPR and AED use through education, research, and collaboration, including overseeing the distribution of £1,000,000 for public access defibrillators and redesigning PAD signage.
Response (NHS England): NHS England acknowledges concerns about out-of-hospital cardiac arrest survival. The Treasury has allocated £2m for public access defibrillators, and the Department for Education has issued guidance encouraging CPR training and …
Response (British Heart Foundation): The BHF provides training resources for CPR and PAD familiarisation, funds PADs, and offers a Genetic Information Service for inherited heart conditions, which they have promoted to coroners.
Responded
Barbara Turner
Concerns: The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.
Overdue
James Fox
Concerns: Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Response (Metropolitan Police Service): The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment …
Responded
Christopher Brennan
Concerns: The adolescent psychiatric unit lacked specific policies for managing self-harm risks from items, and emergency equipment did not include laryngoscopes, despite their prior successful use in airway obstructions.
Overdue
Liam Day
Concerns: The deceased died of hypothermia after deep water soloing; he was not wearing appropriate safety equipment and the dangers of low temperatures in coastal waters were not fully appreciated.
Response (RYA): The RYA has refreshed the safety information pages on its website and will be highlighting this safety information to its members through various electronic communications and in the RYA's annual …
Response (BMC): The BMC will make climbers aware of the risks of dangerously low temperatures in coastal waters, including Cold Water Shock, in their guidance and will raise this with guidebook writers. …
Responded
Margaret Wakefield
Concerns: Critical care haemofiltration was unavailable in a timely manner, leading to patient deterioration and death, indicating a failure in access and contingency planning for vital treatments.
Response (Royal Cornwall Hospital NHS trust): The Trust has increased the funded establishment for registered nurses in the Critical Care Unit, increased hours of operation for the Critical Care Outreach Team to cover the full 24 …
Responded
Sandra Brotherton
Concerns: A sole carer did not have a contingency plan in place for emergencies, a personal assistant's care plan was not clearly documented or provided, and an urgent consultant psychiatrist appointment was difficult to obtain.
Response (Pennine Care NHS Trust): The Trust has updated its audit tool to include questions about contingency plans for carers, reminded care coordinators to document these plans, and developed a 7-minute briefing on this topic …
Responded
Peter Keep
Concerns: The hospital lacked a clear sedation policy for cardiac procedures, leading to inconsistent drug use, inadequate staff training on anxiolytics, and no action plan for patient intolerance or airway emergencies.
Response (Frimley Health NHS Trust): Frimley Health NHS Trust relaunched the Trust Safe Sedation Committee and is reviewing and revising the Trustwide Guideline for Intravenous Conscious Sedation of Adults.
Responded
Terence Millington
Concerns: Inadequate arrangements for on-call doctors, including a senior doctor's failure to ensure availability and a consultant's distant location, delayed prompt emergency care and a blood product request was incorrectly met.
Response (Sheffield Teaching Hospital NHS Trust): Sheffield Teaching Hospital NHS Trust has discussed the incident with the doctor concerned and included reference to on-call responsibilities in the local induction program. An emergency epistaxis bag is now …
Responded
Grant Richards
Concerns: The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.
Overdue
Michael Brennan
Concerns: A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.
Response (University College Hospitals NHS Trust): UCLH will revise its bed management policy by the end of May 2017 to reflect twice-daily bed state updates from Westmoreland Street Hospital. It is also implementing an electronic coordination …
Responded
Patrick Woods
Concerns: The hospital's unknown equipment portfolio prevented the identification of potentially dangerous devices, hindering proper risk assessments and actions to prevent patient injury or fatalities.
Response (Draeger Medical UK Limited): Draeger Medical UK has updated its training documentation, including the Basic Skills Checklist and powerpoint presentation, to address the use of the ACGO switch and relevant ventilation modes. They are …
Response (Luton Dunstable University Hospital): Luton and Dunstable University Hospital has reconfigured default alarm settings on anaesthetic machines, educated staff on unused functionality, and implemented a system to manage medical equipment logs. The Clinical Director …
Overdue
Andrew Wilson
Concerns: No arrangements existed to provide peritoneal dialysis at non-renal hospitals, and treating clinicians were unaware of this service gap or the unavailability of trained staff and equipment.
Overdue
Sousse (Tunisia)
Concerns: Travel companies lacked board-level security advisors and failed to prominently display government travel advice, leaving customers potentially uninformed about terrorism risks in destination countries.
Overdue
William Wilson
Concerns: The establishment lacked a clear system for alerting the designated first aider, and staff who attended the deceased were unfamiliar with basic life-saving first aid techniques.
Overdue
Select committee recommendations(719)— showing 50 strongest matches
#24 —
Recommendation: The Ministry of Defence should work with international partners to ensure there are viable plans to escort cable ships without degrading wider NATO taskings. This plan could usefully include heightened surveillance of suspicious vessel activity, rules of engagement enabling a …
Gov response: The Government partially agrees this recommendation. We agree that escorting ships is an important task, and needs to be prioritised against other NATO tasking, and we routinely review our rules of engagement to ensure these …
Position Not Stated
#23 —
Recommendation: In a heightened threat scenario, we are uncertain about the Royal Navy’s ability to protect vulnerable cable regions and escort repair ships without undermining commitments to other NATO tasks. We admire the Minister for Armed Forces’ optimism that the problem …
Gov response: The Government partially agrees this recommendation. We agree that escorting ships is an important task, and needs to be prioritised against other NATO tasking, and we routinely review our rules of engagement to ensure these …
Response Not Attributed
#16 —
Recommendation: Emergency services should ensure their business continuity plans highlight any areas of critical reliance on foreign internet servers, and account for temporary internet disruption in the event of a security crisis. (Recommendation, Paragraph 100) Legal Responses
Gov response: The Government agrees with the Committee’s recommendation that emergency services should ensure their business continuity plans explicitly identify any critical reliance on foreign internet servers and account for temporary internet disruption in the event of …
Accepted
#15 —
Recommendation: The Department for Science, Innovation and Technology should ensure all lead departments have detailed sector-by-sector technical impact studies on areas most likely to be affected and response plans—notably finance, maritime and air traffic, communications, defence and supply chains including food …
Gov response: . The Government agrees with this recommendation. The UK’s critical sectors must be prepared for reasonable-worst-case subsea cable disruption events. As the Committee notes, DSIT is already working with Lead Government Departments (LGDs) to update …
Accepted
#14 —
Recommendation: The impacts of catastrophic disruption from a co-ordinated attack remain speculative, but are almost certainly highly damaging. We estimate they would include payment and supply chain failures, some degraded communications, overstretched emergency responses, and unexpected cascading issues—all at a time …
Gov response: The Government agrees with this recommendation. The UK’s critical sectors must be prepared for reasonable-worst-case subsea cable disruption events. As the Committee notes, DSIT is already working with Lead Government Departments (LGDs) to update the …
Response Not Attributed
#13 —
Recommendation: The UK has particular vulnerabilities around outlying islands, the financial sector and military communications cables. These should be a key focus for contingency planning. (Conclusion, Paragraph 81)
Gov response: The Government agrees with this recommendation. The UK’s critical sectors must be prepared for reasonable-worst-case subsea cable disruption events. As the Committee notes, DSIT is already working with Lead Government Departments (LGDs) to update the …
Response Not Attributed
#12 —
Recommendation: The Royal Navy should establish a cadre of reservists and serving personnel to learn cable repair skills on commercial repair vessels. These could be called on in periods of heightened tension. (Recommendation, Paragraph 75) Moderate and catastrophic impacts
Gov response: The Government requires more time to consider this recommendation. The Ministry of Defence (MoD) will work with the Department for Energy Security and Net Zero (DESNZ), DSIT and industry to evaluate commercial cable repair capacity …
Position Not Stated
#11 —
Recommendation: The Government should acquire a genuinely sovereign cable repair ship by 2030. This could be leased to industry on favourable terms during peacetime and made available for Government use in a crisis. The Government should set out a timetable for …
Gov response: The Government agrees that there needs to continue to be a UK-based and UK-flagged repair ship for the foreseeable future. A UK based and UK flagged repair ship enables rapid response to cable breaks in …
Accepted
#9 —
Recommendation: The Government’s resilience plans should focus in more detail on the level of immediately available capacity in the cable system during a security crisis. The Department for Science, Innovation and Technology should request operators to provide regular updates on the …
Gov response: The Government agrees with the Committee that there should be more detailed technical plans on management of the UK’s cable systems in the event of serious disruption to subsea cables. The Government will regularly engage …
Accepted
#8 —
Recommendation: The Government’s resilience concept focuses too much on ‘having lots of cables’. This pays insufficient attention to the network’s actual capacity to absorb shocks and does not account for onshore vulnerabilities and long-term trends towards a more brittle system. There …
Gov response: The Government agrees with the Committee that there should be more detailed technical plans on management of the UK’s cable systems in the event of serious disruption to subsea cables. The Government will regularly engage …
Response Not Attributed
#6 —
Recommendation: The National Protective Security Authority (NPSA) and National Cyber Security Centre should require all UK landing stations to be target-hardened to sufficient levels to deter state-backed sabotage. They should require landing station operators to develop within 12 months an emergency …
Gov response: We agree with the Committee on the need to strengthen the security of UK cable landing stations, including target hardening to deter state- backed sabotage. The NPSA and NCSC have already carried out security assessments …
Accepted
#4 —
Recommendation: The Government should update its public and private risk scenarios to cover extensive co-ordinated sabotage to subsea and terrestrial internet infrastructure, including onward connections to Europe. (Recommendation, Paragraph 39) System vulnerabilities
Gov response: The Government agrees with the Committee on the importance of ensuring that public and private risk scenarios reflect the evolving threat landscape, including the potential for coordinated sabotage targeting subsea cables, terrestrial infrastructure, and onward …
Accepted
#3 —
Recommendation: We also found sceptical views in some parts of the cable industry about the risks of co-ordinated attacks. We agree that resilience across the sector is generally robust, major disruption is unlikely, and hype is unhelpful. But we caution against …
Gov response: The Government agrees with the Committee on the importance of ensuring that public and private risk scenarios reflect the evolving threat landscape, including the potential for coordinated sabotage targeting subsea cables, terrestrial infrastructure, and onward …
Response Not Attributed
#2 —
Recommendation: The Government’s resilience assessments must take greater account of the worsening security environment over the next 5–10 years. The National Security Strategy and Strategic Defence Review set out serious preparations for future crises. However, the Minister for Data Protection and …
Gov response: The Government agrees with the Committee on the importance of ensuring that public and private risk scenarios reflect the evolving threat landscape, including the potential for coordinated sabotage targeting subsea cables, terrestrial infrastructure, and onward …
Response Not Attributed
#26 —
Recommendation: As well as continuing its strategic collaboration with the United States where practical, the Government must also develop a clear plan, along with other European allies, for a transition towards greater European leadership of NATO. Preparing for a ‘worst-case scenario’ …
Gov response: The depth and breadth of the UK-US defence and security relationship delivers mutual benefits for both nations. As the Prime Minister said in his speech at the Munich Security Conference, the emphasis should be on …
No Published Response
#16 —
Recommendation: The Government should also set out, in response to this report, how it will strengthen institutional links between the UK Resilience Academy (UKRA) and central government, including by: ○ enabling the UKRA to report into Cabinet Office-led exercises to refresh …
Gov response: The Government agrees with both recommendations. The UK government will maintain responsibility for the delivery of our response plans and preparations. The UK Resilience Academy (UKRA) is committed to enhancing the provision of independent advice …
Accepted
#15 —
Recommendation: The Government should ensure that the UK Resilience Academy is reviewing preparedness plans specifically in relation to the estimated impacts of Reasonable Worst Case Scenarios as set out in the National Risk Register, including the possibility of direct threat to …
Gov response: The Government agrees with both recommendations. The UK government will maintain responsibility for the delivery of our response plans and preparations. The UK Resilience Academy (UKRA) is committed to enhancing the provision of independent advice …
No Published Response
#12 —
Recommendation: The Government must accelerate its plans for improving the size and state of the reserves, and provide more detail for its plans to involve the reserves in the protection of Critical National Infrastructure. This should include planning for their use …
Gov response: The Government is committed to working closely with owners and operators of CNI in the UK to maintain and improve the cyber resilience of our most critical systems. Critical National Infrastructure (CNI) Lead Government Departments …
No Published Response
#4 —
Recommendation: We recommend that the Ministry of Justice and HMPPS set out how the probation service intends to address the backlogs that have built up over the past three months. Additionally, we recommend that the Ministry and HMPPS set out how …
Gov response: Social distancing guidelines require that we maintain restrictions with groups of service users, which affects delivery of both unpaid work (UPW) and Accredited Programmes. This affects both the group work itself but also the transport …
Partially Accepted
#3 —
Recommendation: The model of probation delivery has changed substantially in the weeks since the introduction of the UK lockdown, particularly the way in which case-management supervision is delivered. Additionally, other areas such as unpaid work and interventions have stopped. We recognise …
Gov response: Social distancing guidelines require that we maintain restrictions with groups of service users, which affects delivery of both unpaid work (UPW) and Accredited Programmes. This affects both the group work itself but also the transport …
Partially Accepted
#28 —
Recommendation: The Government has been too slow to respond to the needs of the sectors under the Department for Digital, Culture, Media and Sport’s remit during the Covid-19 outbreak. In its response, DCMS has been hampered by its overall spending power, …
Gov response: 2 This can be found here 3 Government response to the public consultation on implementing the European Electronic Communications Code, July 2020, available here: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/ attachment_data/file/902879/Government_response_EECC.pdf Impact of Covid-19 on DCMS sectors: Government Response 17 …
Position Not Stated
#23 —
Recommendation: The capacity constraints that arise from the requirements of social distancing make yield management and smoothing out demand more important than ever. The Eat Out to Help Out programme will help shift some demand to trough days. Doubtless attractions, transport …
Gov response: The Government has implemented a series of measures to support the extension of the holiday season. For example, businesses will benefit from the cut in VAT for most tourism activities until the end of March …
Position Not Stated
#19 —
Recommendation: Government must address the urgent need for the UK’s cultural industries to be covered by adequate insurance. Without it, efforts to resume filming, touring and live performance are doomed to failure. Alongside working with the insurance industry to introduce a …
Gov response: On 28 July, the Government announced the £500 million Film and TV Production Restart Scheme. This £500 million compensation scheme will assist the film and TV production sectors who are ready to return to work, …
Position Not Stated
#6 —
Recommendation: We also recommend that the Government explain to us how it will incorporate concerns about the resilience and suitability of current IGR structures (particularly the JMC) into its ongoing review of Intergovernmental Relations.
Gov response: The UK Government’s Department for International Trade has launched a UK Trade Hub, based in Edinburgh’s Queen Elizabeth House, to support Scottish businesses. This new Trade Hub will be dedicated to helping businesses in Scotland …
Position Not Stated
#5 —
Recommendation: We have also noted that the Joint Ministerial Committee (JMC) has not been used as a method of intergovernmental communication throughout the pandemic, although we have heard suggestions that it would not have been fit for purpose in the COVID-19 …
Gov response: HM Treasury (HMT) and HM Revenue and Customs (HMRC) have committed to undertaking a detailed evaluation of the Coronavirus Job Retention Scheme (CJRS) and the Self-Employment Income Support Scheme (SEISS). Given the economic and fiscal …
Under Consideration
#4 —
Recommendation: Looking to the future, Ministers must outline, in response to this report, their plans for the coronavirus Cabinet Committees, [Covid-19 Operations Committee and COVID-19 Strategy Committee] and how those Committees will incorporate the priorities of the devolved nations. In view …
Gov response: The report on Exercise Cygnus is available here. Exercise Cygnus identified 22 recommendations (or lessons in the terminology of the report) which were all accepted by the UK Government. For example, lesson 4 recommended that …
Under Consideration
#3 —
Recommendation: We are concerned to hear that Ministerial Implementation Groups (MIGs) and COBRA have ceased to meet in the context of the pandemic. From what we have heard about how communication standards currently stand, decision-makers in devolved nations have come to …
Gov response: and recommend that a timetable of regular intergovernmental meetings should be set up, both during the rest of this pandemic, especially if there is a second wave, but also for after the pandemic. We need …
Position Not Stated
#21 —
Recommendation: Local authorities play a significant role in all parts of the UK government’s response to COVID-19. They have key obligations such as to deliver social care, other parts of the emergency response and support for individuals and businesses. Central government …
No Published Response
#16 —
Recommendation: The Cabinet Office acknowledged that it was taken by surprise by the need for a massive quantity of protective equipment, and by the difficulty of sourcing it from reliable UK-based suppliers.36 It said that a particular challenge was supplying PPE …
No Published Response
#15 —
Recommendation: Many departments are having to source products and services quickly in new or emerging markets, often with complex and varied supply chains. The health and social care supply chain has had to work with pharmaceutical companies, private sector health equipment …
No Published Response
#11 —
Recommendation: The Cabinet Office set out the governance and decision-making structures for the UK government’s response to COVID-19. These comprised four ministerial implementation committees representing health, international, economic and wider public services, led 16 Qq 92–93 17 Qq 105–8 18 Committee …
No Published Response
#6 —
Recommendation: The unit cost paid by the government for PPE and medical equipment is higher than it would have liked but it considers the purchase of this equipment value for money given the alternative of not having enough equipment. However, it …
No Published Response
#5 —
Recommendation: There were fundamental flaws in the government’s central procurement and local distribution of vital goods and equipment. We recognise that the government was faced with a massive challenge to procure a huge quantity of personal protective equipment (PPE) for 58,000 …
No Published Response
#4 —
Recommendation: Effective coordination and command structures are critical for good decision making in any ongoing emergency. The government set up four ministerial implementation committees to coordinate the pandemic response across government, reporting into the COVID-19 group chaired by the Prime Minister, …
No Published Response
#3 —
Recommendation: We are concerned that lessons have not been learned ahead of a potential second spike of infections. It is not clear that the government is undertaking the necessary preparatory work for a second peak of infections. The Department for Business, …
No Published Response
#2 —
Recommendation: We understand and acknowledge that the usual processes for scrutinising and approving spending decisions may need to be relaxed when urgent action is needed during an emergency. In the following paragraph we criticise the transparency over ministerial directions, not the …
No Published Response
#16 —
Recommendation: We are concerned that there does not appear to be a sufficiently clear, separate plan on how the youth custodial estate will transition out of the current lockdown phase. We agree that plans need to be flexible enough to accommodate …
Gov response: Our National Framework is intentionally flexible enough to accommodate the different circumstances and situations of different establishments. It sets out that delivery will vary on this basis, taking into account the needs of children and …
Position Not Stated
#1 —
Recommendation: The Covid-19 pandemic poses an urgent threat to public health and safety. It is an unprecedented situation that has required an immediate response by the prison service to protect the NHS and save lives. We praise the Prison Service and …
Gov response: The Covid-19 pandemic has presented a unique set of challenges that we continue to address to maintain services in custody and the community. Guided by public health advice, we took immediate, decisive action to implement …
Position Not Stated
#6 —
Recommendation: Whilst a relatively large financial package was developed for those suffering from COVID-19 related financial hardship in the UK, little was done to provide help for those UK citizens stuck abroad. The FCO had emergency loans available, but both take …
Gov response: British nationals who are overseas and wish to return to the UK, but cannot afford travel costs and have no other options for getting funds to return home, may apply for an emergency loan from …
Accepted
#5 —
Recommendation: The FCO advised UK citizens to make use of commercial flights, but they did not do enough to help people access those flights. The Government needs to offer support that factors in the reality that for many, just because commercial …
Gov response: The Government was acutely conscious of the difficulties facing British travellers in a range of countries and we recognise that many found getting to airports extremely difficult. Across the world many British travellers were not …
Response Not Attributed
#4 —
Recommendation: Whilst reliance on the commercial system may have been the most cost effective and convenient way to help the majority of travellers return to the UK, for some people this was not a practical solution. This included travellers who were …
Gov response: bring home British travellers. But, as noted above, while charters were the most prominent element of our response, it would not have been possible to return all British nationals travelling overseas at the start of …
Position Not Stated
#3 —
Recommendation: The Government placed too much reliance on commercial carriers at the start of the crisis. We were surprised that the Permanent Under-Secretary and the Minister gave different explanations for their Department’s decision to rely upon commercial flights. This decision was …
Gov response: bring home British travellers. But, as noted above, while charters were the most prominent element of our response, it would not have been possible to return all British nationals travelling overseas at the start of …
Position Not Stated
#53 —
Recommendation: We urge the Home Office to set out a full, public, Covid-19 strategy which addresses the key concerns outlined in this chapter in relation to asylum accommodation and immigration detention. The strategy should cover further periods of local or national …
Gov response: The Government is grateful for the committee’s report and we remain committed to supporting those in our accommodation and those detained in our care, appropriately throughout this changing period. However, we do not believe that …
Position Not Stated
#51 —
Recommendation: On 5 June, the Housing Secretary announced a two month extension, until the end of August, of the suspension of evictions from social or private rented housing to protect tenants and landlords during the pandemic.
Gov response: We welcome the Committee’s recognition of the additional and extended support that the Home Office has provided to asylum seekers whose claims have been fully determined. otherwise no longer be eligible was undertaken in consultation …
Position Not Stated
#50 —
Recommendation: The experience of the pandemic has demonstrated the importance of implementing this Committee’s previous recommendations both in respect of asylum accommodation and immigration detention. We welcome the Home Office’s commitment to proceed carefully “back to a more normal state of …
Gov response: We welcome the Committee’s recognition of the additional and extended support that the Home Office has provided to asylum seekers whose claims have been fully determined. otherwise no longer be eligible was undertaken in consultation …
Position Not Stated
#47 —
Recommendation: While Mears affirms that the dispersal of individuals from Urban House on 10 July without testing, even after cases of Covid-19 were confirmed in the facility, was in line with the national system, we are deeply concerned that the company …
Gov response: The Government expects the highest standards from all of our contractors and we work closely with asylum accommodation providers to monitor and ensure they continue to meet these standards. Throughout the recent pandemic, all providers …
Response Not Attributed
#44 —
Recommendation: Some of the temporary measures introduced by the Government in response to Covid-19 hold open the prospect of future improvements in the operation of both the asylum and immigration removal processes. Among these, the decision to extend asylum support for …
Gov response: COVID-19 global pandemic, the Home Office has been working closely with Public Health leads to put in place a range of measures to support people in the asylum accommodation and immigration removal centre estates. This …
Position Not Stated
#39 —
Recommendation: We welcome the substantial reduction in the number of individuals detained in IRCs since the beginning of the lockdown. This was a sensible response to Covid-19 and will have helped prevent infections.
Gov response: Home Office preparedness for COVID-19 (coronavirus): institutional accommodation: 15
Position Not Stated
#37 —
Recommendation: The Government said that it would review its policy of temporarily pausing all evictions from asylum accommodation and continuing the provision of asylum support before the end of June. In a Parliamentary debate on 17 June, a number of MPs …
Gov response: Replied together with 50. The experience of the pandemic has demonstrated the importance of implementing this Committee’s previous recommendations both in respect of asylum accommodation and immigration detention. We welcome the Home Office’s commitment to …
Not Addressed
#36 —
Recommendation: We call once again on the Home Office and its providers to work closely with housing providers, local authorities and Strategic Migration Partnerships to increase the availability of asylum accommodation both during the period of lockdown, and afterwards. (Paragraph 143) …
Gov response: The Home Office is committed to working collaboratively with communities and stakeholders to ensure that destitute asylum seekers are provided with safe, secure and suitable accommodation. We have established the Local Government Chief Executive Group …
Response Not Attributed
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
CQC inspection actions(69)— 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
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
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
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
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
University Hospital North Durham
The service must ensure staff complete all environmental and emergency equipment safety checks in accordance with trust policy.
Must Do
UHBW Bristol Campus
The service should ensure emergency grab boxes are checked and ready for use.
Should Do
Sunderland Eye Infirmary
Review the arrangements for the role of the Eye Infirmary when dealing with major incident/events across the trust.
Should Do
Darlington Memorial Hospital
The service should consider formal risk assessment of access to emergency resuscitation equipment on PAU.
Should Do
Darlington Memorial Hospital
The service must ensure staff complete all environmental and emergency equipment safety checks in accordance with trust policy.
Must Do
Holly House Residential Care Home
The provider must have adequate arrangements in place to respond appropriately to people’s changing needs and emergencies.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure staff training compliance rates for Resuscitation training level 2 and level 3 are in line with trust targets.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all relevant staff are trained to the highest level of life support. This includes ensuring the Childrens Assessment Unit has a staff member on duty trained in Advanced Paediatric Life Support in line with the Royal …
Must Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallresuscitationchecklistsincludethenameofthelocationandtypeofequipmentnamed.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatthereisoutofhoursseniorsupportinplaceforcommunitymidwivesandcommunitystaffaresuitablytrainedforhomebirthemergencies.Regulation12(1)(2)(b)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatthemissingemergencymedicinefromeachboxisreplaced.Regulation12(1)(2)(g)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatcommunitystaffaresuitablytrainedforhomebirthemergencies.Regulation12(1)(2)(c)
Must Do
Kettering General Hospital
The service should ensure there is a clear documented and risk assessed procedure in place for transferring a paediatric patient from the paediatric emergency department to the resuscitation area in the event of an emergency where required.
Should Do
Ellesmere Port Hospital
The trust must ensure the risks presented by gaps in the out of hours stroke service are effectively assessed and mitigated.
Must Do
Bridgwater Community Hospital
The service must ensure there are effective processes for amending the home birth and midwifery-led unit provision at times of increased demand on ambulance services to ensure timely transfer to the obstetric-led maternity unit is not delayed.
Must Do
Verve Health
This service must ensure that service users have Personal Emergency Evacuation Plan’s (PEEPs) in order to safely support them to evacuate the building in an emergency.
Must Do
The Newcastle Clinic
The service should have a business continuity plan.
Should Do
Sydenham House
Ensure there is an effective system in place for the provision and monitoring of emergency medicines and equipment, in the event of a medical emergency.
Should Do
Spindrift Care Home Limited
Risk assessments and measures to reduce risks to people who lived at the home were not always up to date and reflective of people's current needs.The provider's business continuity plan was not up to date and required review. Personal Emergency …
Must Do
Verve Health
the service must have a clear process for staff to follow in case or medical or clinical emergencies.
Must Do
Worthing Hospital
The trust must ensure equipment in ward and theatre environments is moved or stored in a suitable location and avoids emergency exits being blocked.
Must Do
William Harvey Hospital
The trust must ensure that fire safety risks associated with an overcrowded department are assessed and mitigated. For example, with regard to trolleys blocking corridors and fire exits.
Must Do
The Queen Elizabeth Hospital
The service should ensure staff whomay have to provide care for out-of-scope events are giving training to do so.
Should Do
St Richard's Hospital
The trust must ensure equipment in ward and theatre environments is moved or stored in a suitable location and avoids emergency exits being blocked.
Must Do
Royal Sussex County Hospital
The trust must ensure equipment in ward environments is moved or stored in a suitable location and avoids emergency exits being blocked.
Must Do
Royal Sussex County Hospital
The trust must ensure equipment in ward and theatre environments is moved or stored to a suitable location and avoids emergency exits being blocked.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that fire safety risks associated with an overcrowded department are assessed and mitigated. For example, with regard to trolleys blocking corridors and fire exits.
Must Do
Ormskirk District General Hospital
The service must ensure all staff are up to date with mandatory training including but not limited to pool evacuation.
Must Do
Montagu Hospital, Mexborough
ThetrustshouldensuretheMIUambulance/resuscitationroomisprotectedfromfloodriskanddoesnotpreventpatientswhoneedemergencycarefromaccessingtreatmentonsite.
Should 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 …
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(2)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 6b
The Welsh Government should accelerate implementation of a national maternity bed and neonatal bed/cot locator with 24/7 availability, dedicated staffing, senior clinical oversight and a single point of access.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 6a
The NHS Wales Joint Commissioning Committee should urgently complete analysis and commissioning decisions on neonatal cot configuration, neonatal transport and transitional care capacity.
wales
Accepted
Scottish Fatal Accident Inquiries(7)
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
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
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
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
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