Emergency family notification
Failure to notify family members about a patient's condition or transfer in emergency situations, causing distress.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
15 inquiry recs
113 PFD reports
8 committee recs
1 HSSIB rec
2 CQC actions
1 ICIBI rec
28 PPO recs
6 IOPC recs
17 IMB recs
1 IMB report
1 Scottish FAI
5 Article 2 learning points
58 PHSO decisions
3 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(15)
FENN-153 — Agree common system for casualty identification and fatality documentation in London
Recommendation: A uniform documentation procedure for handling and receiving fatalities should be considered. In London all the services must meanwhile agree a common system for identification of casualties and recording the position in which they are found.
Unknown
LADB-4 — Review railway emergency planning, including survivor after-care and bereaved support
Recommendation: The Railway Group should review emergency planning, including liaison with the emergency services, arrangements for the after-care of survivors and the provision of support and facilities for the bereaved and injured (para 4.122).
Unknown
MACP-26 — Ensure Senior Investigating Officers provide comprehensive information and manage family liaison.
Recommendation: That Senior Investigating Officers and Family Liaison Officers be made aware that good practice and their positive duty shall be the satisfactory management of family liaison, together with the provision to a victim's family of all possible information about the …
Unknown
MACP-23 — Ensure readily available designated and trained Family Liaison Officers at local level
Recommendation: That Police Services should ensure that at local level there are readily available designated and trained Family Liaison Officers.
Unknown
BAHA-16 — Death in Custody Checklist
Recommendation: JDP 1-10 should include a simple checklist for actions on a death in custody. Where there is a death in custody, particularly one that is sudden or unexplained, prompt checks must be made on the welfare of other CPErS. The …
Gov response: Accepted. A death in custody checklist has been developed, including scene preservation guidance.
Accepted
LADB-3 — Establish common telephone numbers for public major incident information
Recommendation: The police service, in co-operation with the emergency services, should use their best endeavours to ensure that common telephone numbers are issued for the use of members of the public who are seeking to give or obtain information about persons …
Unknown
LADB-2 — Extend computerisation to all police forces for shared information access
Recommendation: Computerisation should be extended to all police forces, so that the information collated by each is readily available to all others (para 4.120).
Unknown
LADB-1 — Computerise system for managing missing persons and casualty information
Recommendation: The system for the reception of information about missing persons, casualties and survivors should be computerised. It should be possible for information which has been received to be entered directly into the computer and for information from it to be …
Unknown
MACP-28 — Proactively use local minority ethnic contacts for family liaison assistance.
Recommendation: That Police Services and Victim Support Services ensure that their systems provide for the pro-active use of local contacts within minority ethnic communities to assist with family liaison where appropriate.
Unknown
MACP-27 — Formally record and report all family requests and complaints to superior officers.
Recommendation: That good practice shall provide that any request made by the family of a victim which is not acceded to, and any complaint by any member of the family, shall be formally recorded by the SIO and shall be reported …
Unknown
MACP-25 — Dedicate Family Liaison Officers primarily or exclusively to their liaison task
Recommendation: That Family Liaison Officers shall, where appointed, be dedicated primarily if not exclusively to that task.
Unknown
MACP-24 — Include racism awareness and cultural diversity training for Family Liaison Officers
Recommendation: That training of Family Liaison Officers must include training in racism awareness and cultural diversity, so that families are treated appropriately, professionally, with respect and according to their needs.
Unknown
IHRD-43 — GP Notification of Death Circumstances
Recommendation: A deceased's family GP should be notified promptly as to the circumstances of death to enable support to be offered in bereavement.
Gov response: GP notification procedures established for SAI-related deaths.
Accepted
F174 — Candour about harm
Recommendation: Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
DM-5 — Separate SIO and Family Liaison Officer roles
Recommendation: The Metropolitan Police should ensure that the role of the Family Liaison Officer is never carried out by the Senior Investigating Officer of an investigation. There is an inherent conflict between these two roles.
Gov response: The new National Major Crime Investigation Manual (MCIM) published in November 2021 covers all aspects of major crime investigation and sets the standard for all forces alongside the relevant Authorised Professional Practice (APP) produced by …
Accepted
Prevention of Future Deaths reports(113)— showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner's concern relates to circumstances that could create a risk of future deaths, and action should be taken to prevent such occurrences.
Overdue
Annie Rose Gibson
Concerns: The coroner raises concerns about a lack of clarity in Saga Homecare's procedures, specifically regarding the recording and communication of observations after a client fall.
Overdue
Clive Gould
Concerns: Ambulance service failures include inappropriate priority allocation for calls, insufficient system resilience leading to delays, and inadequate communication with callers about estimated arrival times and potential delays.
Response (South Central Ambulance Service): South Central Ambulance Service has extended Rapid Response Vehicle cover to 24 hours in Oxfordshire, Buckinghamshire and Berkshire. Rota match versus demand has also been reviewed. They have developed a …
Responded
Christopher James Morgan
Concerns: The Trust lacks clear policies for communicating risk level changes and leave access with family, and has no defined staff-to-patient ratio for escorted leave from psychiatric wards.
Overdue
Daniel Maurice McMahon
Concerns: The report suggests improving information gathering by police when someone is trespassing on railway tracks; using feedback forms for patients on S17 MHA leave; amending the rule book to require trains to stop when a potentially unwell person is trespassing; and reviewing guidance on lung decompression needles for the ambulance service.
Response (Response R): The London Ambulance Service reviewed the use of one-way valves on needle chest decompressions and concluded that their current approach of not using them is appropriate, citing expert opinions and …
Response: The Department of Health is reviewing the advice in the 'Code of Practice Mental Health Act 1983', including the chapter on leave of absence under section 17 and references to …
Overdue
James Stokoe
Concerns: Mental Health Services lack formal mechanisms to consult carers/partners, potentially missing vital information that could inform risk assessments and identify domestic abuse, especially in elderly patients.
Overdue
Noel Williams
Concerns: The coroner noted a failure to communicate haemoglobin level test results, which are an important factor in considering a patient's fitness for surgery, to the anaesthetist and surgeon, potentially affecting treatment plans.
Overdue
Jean James
Concerns: Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Response (City Hospitals Sunderland): The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the …
Responded
Charles Bradley
Concerns: Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Overdue
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
Robert Jones
Concerns: CT scan results were not made available promptly to relevant departments, nor were they acted upon without delay and within a reasonable timeframe.
Response: The Radiology department will sample emergency CT scan report times. All staff will be reminded to document review of test results, and verbal results. A report on these actions will …
Responded
Caroline Pilkington
Concerns: North West Ambulance Service staff lack control and restraint training, forcing reliance on police who are not clinically trained, leading to delayed patient care and inappropriate diversion of police resources.
Response (Greater Manchester Police): Greater Manchester Police expresses concern about the increasing demand on police due to gaps in health services, emphasises that officers are trained in restraint but that medical emergencies require different …
Response (North West Ambulance Service NHS Trust): NWAS acknowledges the coroner's concerns but maintains that ambulance staff are not trained nor expected to restrain patients who are acting in a threatening or violent manner, as advanced control …
Response (Department of Health): The Department of Health acknowledges the coroner's concerns but supports the NWAS's collaborative approach with the police in handling patients requiring advanced control and restraint.
Response (Department of Health2): The Department of Health acknowledges the coroner's concerns about NWAS training, but supports the NWAS position that ambulance staff are sufficiently trained and that more advanced restraint training is not …
Responded
Graham Watts
Concerns: The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Response (Brighton Sussex University Hospitals NHS Trust): A social worker has started attending daily "Board Round" meetings to assist in patient discharge planning. The Trust acknowledges shortcomings in the discharge planning process and is aiming to start …
Responded
Terence Dooley
Concerns: The call concerning the deceased was given a code green despite the fact that each different tablet could be fatal on its own, let alone together.
Response (North West Ambulance Service NHS Trust): NWAS defends its call coding system and response times, stating that the call was coded correctly and all immediately life-threatening calls were responded to within national targets. They dispute there …
Responded
Alun Sheppard
Concerns: The Health Board struggles to balance patient confidentiality with the crucial need for familial support to optimize recovery, potentially hindering patient well-being.
Response (NHS Wales): The Health Board agrees that familial support improves patient recovery and routinely encourages service users to engage with their families. The policy of the Health Board is to use a …
Responded
Marion Turner
Concerns: The report identifies that a message left for the deceased's CPN regarding concerns about her mental health was not read until after her death.
Overdue
Silvia Taylor
Concerns: The service failed to act promptly on unsuccessful attempts to contact Mrs. Taylor and did not communicate these critical difficulties to her family, delaying potential intervention.
Response (Care UK): Care UK reviewed and updated its policy regarding procedures when telephone calls to patients needing assessment by the out-of-hours GP service are unanswered.
Overdue
Joshua Brown
Concerns: The community health team lacked formal processes for family involvement and information sharing, especially when the patient withheld consent, hindering their ability to support him and verify information accuracy.
Response (Department of Health): The Department of Health references existing guidance regarding information sharing with family members and mental capacity assessments in cases of suicide risk, but does not outline any new action being …
Overdue
Graham Darby
Concerns: A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
Overdue
Roseanne Cooke
Concerns: Lack of inpatient psychological support, delayed/confused referrals, and critical communication breakdowns between family and care teams resulted in inadequate post-discharge support for a vulnerable patient.
Response (5 Borough Partnership NHS): The Trust has looked into the concerns raised and has put an action plan in place after a period of no psychological input on the Grasmere Unit due to maternity …
Responded
Simon Satchwell
Concerns: Concerns relate to the lack of clear, consistent international regulations for minors operating jet skis, particularly regarding age restrictions and required adult supervision, differing from UK safety standards.
Overdue
Colin Tyson
Concerns: Concerns were raised about GPs' interpretation of patient confidentiality, which may prevent family members from sharing vital information about vulnerable individuals at risk of suicide.
Response (NHS England): NHS England, working with NHS Wakefield CCG, has developed an advice sheet for GP practices on responding to third-party concerns about patients, which will be shared across Wakefield and Yorkshire …
Responded
Archie Hexall
Concerns: A communication breakdown between midwives led to critical information about a newborn's respiratory distress being lost, with temporary notes not retained and parents left uninformed.
Response (Lewisham Greenwich NHS Trust): Lewisham Greenwich NHS Trust has implemented actions, including a 'learning from incidents' policy requiring staff to document and handover clear information and a review of handover documentation. They have also …
Responded
Margaret Wright
Concerns: Doctors did not routinely telephone patients or families after home visit requests to obtain further information, potentially delaying priority visits and impacting outcomes.
Response (Department of Health): NHS England's Primary Care Patient Safety Expert Group will consider home visits at their next meeting. NICE is drawing up guidance on Home Care with planned publication in September 2015.
Responded
Julia Hayward
Concerns: Discharged mental health patients' care plans, especially those involving family obligations, were only verbally agreed and not documented or provided, leading to critical misunderstandings.
Response (Department of Health): The response explains existing protocols and guidance related to the Mental Health Act and assessment/discharge procedures, but does not describe any specific action taken or planned in response to the …
Responded
William Abel
Concerns: Failure to conduct a Mental Health Act assessment and inadequate communication with family regarding the patient's suicidal intentions and mental health relapse led to unsafe discharge.
Response (Leicester Partnership NHS Trust): The Trust conducted a serious incident investigation and shared the results with the deceased's father. The Triage Car service manager and team manager reviewed decisions made on the night, and …
Responded
Frank Mellers
Concerns: The report identifies that the patient's DNAR status was fixed without family consultation, poor communication between staff led to resuscitation attempts despite the DNAR, and guidelines for DNAR communication may need examination.
Response (Frank Mellers): Following a Root Cause Analysis, the importance of ward rounds has been reiterated, a DNAR indicator has been developed on ward boards, the DNAR policy has been reviewed, and a …
Overdue
Edna Cleaton
Concerns: The practice lacked systems for regular medical reviews of patients on citalopram, resulting in a three-year delay in review and a missed opportunity to identify deterioration.
Response (Edna Cleaton): Midlands Medical Partnership has an agreed repeat prescribing protocol requiring reviews every six months for antidepressant prescriptions. They have also implemented an automatic electronic protocol within their clinical system that …
Responded
Joanne French
Concerns: Early patient discharge was hampered by unclear assessment requirements, a failure to include family input in decision-making, and inaccurate or incomplete discharge assessment notes.
Overdue
Brenda Morris
Concerns: Lack of communication with the partner regarding leave conditions and no routine family feedback were identified. There was also confusion about doctor authorisation for unplanned leave and substandard documentation.
Response (East London NHS Trust): The Trust has developed an 'In-patient leave agreement' and an 'In-patient leave checklist' to be completed before a patient goes on leave, with a pilot on older persons wards aiming …
Responded
Patricia Medland
Concerns: The patient's daughter was unaware of her designated role as a protective factor in the care plan, potentially preventing her from recognising signs of her mother's mental health relapse.
Response (Brampton Surgery): The practice agreed to encourage sharing appropriate information with relatives and carers, always discussing this with the patient, and has informed the NHS Northern, Eastern and Western Clinical Commissioning Group …
Responded
Lisa Day
Concerns: The 111 service failed to discuss alternative hospital transport with the patient's friend and did not explain the severe risks of a vomiting illness in a diabetic.
Response (Lisa Day Response2): LAS agreed a process with NHS 111 to electronically flag calls with clinical concerns; this system was introduced on 14 March 2016. Training bulletin TB 02/16 and flowchart v2.0 give …
Response (Lisa Day): London Central & West Unscheduled Care Collaborative (LCW UCC) has raised concerns regarding additional scripting of condition-specific information for type 1 diabetes with the National NHS Pathways team. Changes to …
Overdue
Mandeep Singh
Concerns: Ambulance arrival was significantly delayed due to severe demand, staff shortages, and challenges presented by road closures and diversions.
Response (North East Ambulance Service): NEAS has improved its paramedic resource base, with improved attrition rates, and is working to educate the public about appropriate use of services. They work with other agencies for road …
Responded
Monica Lewis-Hinds
Concerns: The ambulance service's call triage protocol is inadequate as call handlers do not proactively ask about the "type of fit," potentially missing critical information for patient care.
Overdue
Jack Susianta
Concerns: Critical information about Jack's expected recovery, symptom recurrence, and urgent help protocols was not communicated to his family, preventing them from seeking timely hospital readmission.
Overdue
Samuel Carroll
Concerns: Police and ambulance services failed to obtain consent to inform family or friends about a patient's suicidal ideation and hospital attendance, leaving them unaware of his critical mental state.
Response (Yorkshire Ambulance Service): Yorkshire Ambulance Service states they are not primarily responsible for contacting family members when conveying a patient to the hospital, but would do so when making referrals to other services. …
Response (North Yorkshire Police): North Yorkshire Police will amend its Mental Health and Suicidal People Policy to reflect the College of Policing's Authorised Professional Practice by April 2017. It will also include instruction to …
Responded
James Flynn
Concerns: Inadequate planning led to a very unwell, elderly diabetic patient being discharged late at night without a detailed care plan, family notification, or essential provisions at home.
Overdue
Charles Woodward
Concerns: Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.
Overdue
Georgina Lewis
Concerns: Concerns included the lack of family notification or consultation regarding discharge, absence of a discharge plan or follow-up support, and no contemporaneous GP notification. These failures left the patient without crucial support post-discharge.
Overdue
Emily Voukelatou
Concerns: The crisis team routinely failed to involve family in patient care, leading to lost input. Repeated unreturned calls from worried relatives also indicated poor communication and information handling within the service.
Response (Camden and Islington NHS Trust): The Trust stresses the importance of family input and states it is routinely assessed, with patient consent, throughout the care pathway. The trust issued guidance to staff at North Camden …
Responded
Debrata Sircar
Concerns: A significant delay in securing a mental health bed and conducting an MHA assessment, coupled with the absence of an interim care plan, compromised care for a patient at high risk of falls.
Response (Oxleas NHS Foundation Trust): Oxleas NHS Foundation Trust has changed its practice so that a referral for a MHA assessment triggers a review of zoning and risk management plan, and the client should be …
Overdue
Doreen Stapleton
Concerns: An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family about the fatal risks of missed medication and follow-up contact.
Response (Whittington Health NHS): The organisation has written to doctors, nurses and pharmacists highlighting learning points. They raised the issues at the Medical Committee and reintroduced patient leaflets about pulmonary emboli on inpatient wards, …
Responded
Mariana Pinto
Concerns: The emergency department failed to effectively communicate illness progression and crisis team limitations to the family. The crisis line nurse did not escalate an urgent situation or prompt emergency services involvement.
Response (response Pinto): East London NHS Foundation Trust is developing a written discharge care plan to clarify the limitations of the Home Treatment Team, and will increase flexibility to bring forward visits for …
Response (East London NHS Trust): Following a serious incident review, the Trust updated its Operational Policy for CMHT, mandating that opt-in letters be sent within 5 working days, and will conduct local audits to ensure …
Responded
John Ramsden
Concerns: Inadequate family consultation occurred, as only one of three daughters was involved in critical end-of-life care decisions, including hospital admission.
Overdue
Rasikaben Chauhan
Concerns: There is a lack of clear communication and awareness-raising regarding a specific risk with relevant community and religious organisations.
Response (Northampton County Council): The fire service has made the risks and circumstances which led to the death known to other UK Fire Services. They are also working with local community groups to deliver …
Overdue
Barbara Sturgess
Concerns: The hospital failed to promptly and formally communicate a patient's cervical spinal fracture and necessary care measures to the nursing home and GP practice, potentially jeopardizing their well-being.
Overdue
Melvin James
Concerns: The hospital discharged a patient without adequate mental health assessment, failing to communicate with family about ongoing delusions or provide formal referral and aftercare to local mental health services.
Overdue
Conall Gould
Concerns: The patient and carers were not informed of a crucial follow-up mental health appointment post-discharge, as the Trust lacked a policy requiring written confirmation. This created a significant risk of missed appointments and inadequate care review.
Response (Conall Patrick): The Northern Health and Social Care Trust has introduced a requirement for written confirmation of follow-up appointments and contact numbers to be provided to patients and, with consent, their relatives/concerned …
Responded
Gillian O’Keefe
Concerns: The patient was illogically discharged from mental health care for "non-engagement" despite acute deterioration, without a multidisciplinary meeting or follow-up procedure for GP concerns. The family also faced barriers in sharing critical information with professionals.
Response (South West London and St Georges Hospital NHS Trust): The Clinical Director is scoping a quality improvement project focusing on family/carer engagement and primary care liaison. A learning event is being organized to share actions and promote reflection. The …
Response (Department of Health): The Trust is working to produce guidance for GPs on raising concerns and referrals and is looking to strengthen family and carer engagement and primary care liaison. The CCG will …
Response (Cricket Green Medical Practice): Cricket Green Medical Practice acknowledges the coroner's report and confirms a Significant Event Analysis (SEA) was undertaken. They note actions the GP practice took and actions the CCG could have …
Responded
Ryan Vout
Concerns: There was a lack of coordinated psychiatric discharge, failing to involve professionals and family. Also, ambulances could not be pre-arranged for Mental Health Act warrants, and pre-entry risk assessments lacked formality.
Response (Nottinghamshire County Council): Nottinghamshire County Council has developed a more robust process for communicating demographics and essential risk information in relation to s135(1) warrants between AMHPs and the Police, including a typewritten document …
Response (East Midlands Ambulance Service NHS Trust): EMAS acknowledges its responsibility to provide timely ambulance service for patients with mental health needs. EMAS plans to adapt its operating model with an urgent care tier, which will go …
Response (Department of Health): The Department of Health acknowledges the concerns raised, focusing on discharge planning and transport for patients sectioned under the Mental Health Act. They state that these matters are operational and …
Responded
Select committee recommendations(8)
#23 —
Recommendation: The UK Government is judged on how it cares for its citizens at home and overseas. In Iran, the Government failed to assert and secure its rights under the Vienna Convention to provide consular assistance to UK nationals held in …
Gov response: 24. The Government is determined to deter and combat the practice of arbitrary detention for the purpose of diplomatic leverage. Such detentions generally occur in countries where human rights standards and the rule of law …
Under Consideration
#21 —
Recommendation: We recommend that if a family believes their case would be best served by going public, the Government should have frank, detailed and regular conversations with them on the likely impacts of their decision and advise on how to proceed …
Gov response: 40. The Iranian Government has put detained British nationals and their loved ones through unimaginably difficult ordeals. Iran was in no doubt that its unfair detention of British nationals was a priority for this government …
Accepted
#26 —
Recommendation: We recommend that unless the detainee expressly withholds consent to do so, the families of any vulnerable or arbitrary detainee receiving consular assistance be provided by a senior manager or minister in the FCDO at the soonest possible time with …
Gov response: 50. The Government recognises the ordeal faced by families and friends of those detained for diplomatic leverage. Families are both victims and valuable partners. Where families have deep links with the detaining country, they may …
Position Not Stated
#25 —
Recommendation: The working assumption should be that families are partners who have the potential to be instrumental in the attempts to resolve the detentions. Despite Government assurances, we do not believe that sufficient progress has been made in improving communication with …
Gov response: 26. The Government does not agree that we should establish a separate post of Director for Arbitrary and Complex Detentions. Our approach reflects the Foreign Secretary’s 8 Stolen years: combatting state hostage diplomacy: Government Response …
Not Accepted
#22 — Rural communities receive minimal NHS mental health support during and after crisis events.
Recommendation: Crisis events can have short- and long-term effects on people’s mental health, but civil society groups told us NHS support is minimal or short-term, despite greater support being likely to help people deal more successfully with trauma. Rural health providers …
Gov response: Defra contributed to the UK Health Security Agency’s published guidance on providing advice about the impacts of being flooded on people’s mental health: • Flooding health advice: mental health - GOV.UK (www.gov.uk), • Flooding and …
Response Not Attributed
#16 — Provide further information on offender’s illness to aid relatives of mentally disordered victims.
Recommendation: To aid close relatives of victims of mentally disordered offenders to cope and recover from their trauma, the Government should consider whether further information could be provided on the nature of the offender’s illness and how it impacted upon the …
Gov response: 22. We acknowledge the Committee’s intention is to support victims to cope and recover, including those who have lost their loved ones. We will consider this complex issue further and assess whether there is an …
Under Consideration
#4 — Individuals have assisted loved ones in pursuing assisted dying abroad.
Recommendation: During our inquiry we have heard statements from people who have been involved in assisting a loved one to pursue AD/AS abroad.
Response Not Attributed
#15 — Local communities impacted by HS2 pause, seeking transparency and input on interim solutions.
Recommendation: We heard concerns from the London Borough of Camden and Drummond Street Traders, who already face many years of disruption, and impact of the pause in construction on local residents and businesses and be absolutely transparent when it is possible …
Gov response: 1.1 The government agrees with the Committee’s recommendation. Target implementation date: Summer 2025 1.2 The government has commenced the Euston Reset Programme, which aims to develop an affordable Euston campus that maximises delivery of benefits …
Not Addressed
CQC inspection actions(2)
Floron Residential Home for the Elderly
We recommend the provider seeks guidance from a reputable source in family involvement in people's care.
Should Do
Floron Residential Home for the Elderly
We recommend the provider seeks good practice guidance in relation to communicating visiting arrangements to relatives.
Should Do
ICIBI immigration recommendations(1)
PPO death in custody recommendations(28)
The Director at Parc
The Director at Parc should ensure that staff ensure that the next of kin are promptly informed when a seriously ill prisoner is taken to hospital.
The Governor
The Governor should ensure that when a prisoner is taken to hospital seriously ill, their next of kin is informed without delay, are provided with comprehensive and accurate information and are kept informed of progress.
The Director
The Director should ensure that staff inform the next of kin immediately when a prisoner becomes seriously ill, in line with Prison Rule 22 and PSI 64/2011.
The Governor
The Governor should ensure that if a prisoner is suspected of, or confirmed as having contracted COVID-19, he is given the opportunity for someone to be notified.
The Governor
The Governor should ensure that, in line with national policy, prisoners’ next of kin are notified promptly when a prisoner becomes seriously ill and that there is a full record of contact and action taken.
The Governor of HMP Lancaster Farms
The Governor should ensure that a family liaison officer is appointed when a prisoner becomes seriously ill and that appropriate arrangements are made to ensure early contact with families.
The Governor
The Governor should ensure that if a prisoner becomes seriously ill, their next of kin is notified immediately, in line with Prison Rule 22 and Prison Service Instruction 64/2011.
The Governor of Isle of Man Prison
The Governor should ensure in the event of a death in custody, prisoners’ in-cell telephones should be disconnected immediately to avoid families being notified before the prison have an opportunity to break the news.
The Director at Parc
The Director at Parc should ensure that staff involve the prisoner’s next of kin in their care where appropriate, in line with PSI 64/2011;
The Governor of HMP Risley
The Governor should appoint a family liaison officer as soon as a prisoner becomes seriously ill, to enable timely contact with the next of kin or other family members in accordance with PSU 64/2011.
The Director (of HMP Parc)
The Director should ensure that a family liaison officer is allocated as soon as possible when a prisoner becomes terminally or seriously ill, in compliance with Prison Service Instruction (PSI) 64/2011 Managing prisoner safety in custody.
The Governor
The Governor should ensure that a family liaison officer breaks the news of a death to a next of kin in person as soon as possible, in line with PSI 64/2011.
The Governor
The Governor should ensure that a family liaison officer is appointed for prisoners who are seriously ill and that official contact is made with a next of kin as soon as possible in line with PSI 64/2011.
The Director
The Director should ensure that a member of Prison Service staff informs a prisoner’s next of kin of their death promptly, in line with national guidance.
The Governor
The Governor should ensure that there are sufficient trained family liaison officers to contact and provide effective and consistent support for bereaved families.
The Governor of Stafford
The Governor of Stafford should ensure that family liaison officers make families aware of the financial support available to them for funeral expenses following a death in custody.
The Governor of HMP Swaleside
The Governor should satisfy herself that the prison has sufficient trained family liaison officers and that senior managers understand the national guidance on liaising with the next of kin following a death.
The Director of HMP Peterborough
The Director should ensure that staff: • promptly inform foreign national prisoners of any delay to their expected release/deportation date; • carry out a face-to-face welfare check, using the services of an interpreter if necessary, to assess the prisoner’s risk …
The Governor
The Governor should ensure that the method of communication with bereaved families is appropriate to their needs and that all contact is fully documented.
The Governor of The Mount
The Governor of The Mount should ensure that when the police break the news of a prisoner’s death to their next of kin, the family liaison officer keeps in contact with the police so that they are kept updated about …
The Governor
The Governor should ensure that when a prisoner dies, a letter of condolence is sent to his family or next of kin, in line with national policy.
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that staff manage prisoners at risk of suicide or self-harm in line with policy, and in particular, staff should: ensure relevant staff involved in the prisoner’s care, including healthcare staff where appropriate, …
The Governor of HMP Berwyn
The Governor should ensure that OMU staff: alert wing staff to the sharing of any potential bad news, so that they can manage this appropriately and provide additional support, if necessary.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff have a clear understanding of their responsibilities to manage prisoners at risk of suicide and self-harm in line with national guidelines, including that: a named consistent case manager chairs …
The Governor of HMP Downview
Downview has protocols for support following deaths in custody, but there do not appear to be formalised procedures for deaths following release. Deaths shortly after release are not frequent and so the situation may not have arisen previously, but the …
The Governor
The Governor should ensure that applications for early release on compassionate grounds for prisoners who meet the criteria are progressed and if in doubt staff should seek advice from HMPPS’ Public Protection Casework Section (PPCS).
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with national guidelines, including that staff: set effective caremap actions that are specific and meaningful, aimed at reducing risk, and …
The Governor of HMP Holme House
The Governor should review the current provision of radios to ensure it is sufficient to meet the needs of the prison.
IOPC learning recommendations(6)
Recommendations - West Midlands Police, July 2020
The IOPC recommends that West Midlands Police introduce a policy/practice which ensures an officer of designated rank (the IOPC suggests Inspector or above) has overall responsibility for identifying Next of Kin and ensuring appropriate delivery of the death message, in …
National recommendations - National Police Chiefs Council, September 2020
The IOPC recommends that the NPCC lead for complaints and misconduct works with all forces to ensure that requirements around delivering the message about a police-related death are clear and understood. This includes the requirement that the senior officer on …
Police response to notify family of woman’s death – South Yorkshire Police, …
The IOPC recommends that the College of Policing should issue appropriate advice on delivering a death message where the person receiving the message is not in their own home. This should set out a requirement for a dynamic risk assessment …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police adopts the principles set out in the force FLO policy as best practice for all officers/staff when dealing with bereaved families. There should be clear agreement in advance about what information can be …
Contact with man before his death – North Wales Police, November 2021
The IOPC recommends that North Wales Police allocates a dedicated Single Point of Contact (SPOC) to families/next of kin during Missing Person Investigations where possible. The SPOC should ensure the family know who their SPOC is, provide regular, meaningful updates …
Investigation into police response to a report that a person was missing …
The IOPC recommends that Northumbria Police revise the ‘Northumbria Procedure – Investigations of Missing Persons’ document to ensure that the following are clear: • Who is responsible for appointing (and communicating) a single point of contact for the family, during …
IMB individual recommendations(17)
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
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Board repeats its recommendation, previously rejected, that the Home Office should provide residential accommodation for children at Heathrow so that they are not restricted to small rooms with no natural light and no fresh air for many hours. For those waiting for turnaround flights, the family detention facility at Tinsley House is too far away for …
Home Office
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport T5] The Home Office should improve the facilities for families and children in Terminal 5 (paras. 6.10 - 6.11).
Home Office
Gatwick pre-departure accommodation (2020)
We ask the contractor PDA managers to ensure that, where a removal is likely to be traumatic, careful planning is consistently used, to avoid children being exposed to their parents’ distress.
Governor / Director
Kent Coast Short Term Holding Facilities (STHF) (2023)
Detained people should be given information of their ‘process journey’. The Board continues to note that the welfare of detained people has been adversely affected by a lack of understanding of where they are being taken and understands that work has begun to address this issue but is disappointed as to the length of time that it has taken to …
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
The Board is concerned about late night moves involving families and children with particular concerns where Taxis are being used. We are very concerned about the potential for a medical emergency arising during a lengthy overnight journey.
Other
Kent Coast Short Term Holding Facilities (STHF) (2024)
The Board has observed that detained people are still in need of information about their ‘process journey’. We continue to note that the welfare of detained individuals has been sometimes adversely affected by their lack of understanding about where they are being taken. The Board understands that work has begun to address this issue, but we are disappointed about the …
Other
In Progress
Gatwick IRC (2021)
There should be some supplementary basic information provided by the Home Office on the steps in the asylum claim process that arrivals will go through while held in the RSTHF. The Home Office should follow the suggestion in paragraph 8 of Detention Services Order 06/2013 to repeat the important basic information through use of a format such as posters and …
Home Office
Heathrow Immigration Removal Centre (2020)
The practice of conducting the majority of DET consultations with detainees over the telephone should be reviewed in order to ensure that all discussions which might be considered ‘sensitive’ are held in person, whilst in line with whatever Government pandemic guidance is current at the time.
Home Office
Deerbolt (2020)
The Minister should agree that the use of video-links for visits and funerals has shown benefits, and that it would be worth trying to develop these techniques with the best of modern technology for regular use in future, albeit not replacing all face-to-face visits, or funeral attendance.
Ministry of Justice
In Progress
Lowdham Grange (2022)
To give priority for the training of family liaison officers (FLOs) in 2022 so that appropriate resources are allocated for this important role and to support those volunteer prison staff already undertaking it.
HMPPS
In Progress
Kent Coast Short Term Holding Facilities (STHF) (2022)
Detained people should be given information of their ‘process journey’ The Board continues to note that the welfare of detained individuals has been adversely affected by a lack of understanding of where they are moving to and why. This occurs particularly in holding rooms. The Board understands that work has begun to address this issue but is disappointed as to …
Home Office
Berwyn (2023)
The Board is concerned that out of area transfers cause difficulties for prisoners, who are far from their families, and for the prison, particularly because these prisoners are not known to the prison. This huge increase in prisoner churn makes it difficult to locate many prisoners safely, especially those who are not part of the regular prison population cohort.
HMPPS
Charter Flight Monitoring Team (CFMT) (2024)
The use of single aisle aircraft presents a challenge to both the Chief Immigration Officer (CIO, an Immigration Enforcement representative who travels on flights) and the returnees wishing to speak with the CIO. On occasion, the CIO is unable to talk to everyone because aisles are blocked for (flight) operational reasons. Consideration should be given as to how the CIO’s …
Home Office
Rejected
Leyhill (2022)
What further action will be taken to deal with the recurring problem of property lost or mislaid during transfer from other prisons?
HMPPS
In Progress
Kirklevington Grange (2022)
There are still issues with property when prisoners move between prisons, especially when moving from privately run establishments to Kirklevington. This does not only apply to Kirklevington, as it is a point of discussion between IMB chairs. It is unsettling when prisoners experience long delays in receiving their belongings and in too many cases property is lost in transit between …
HMPPS
Kirkham (2022)
It is recommended that prisoners are transferred with an overnight bag only, with remaining property delivered the following day or as soon as possible following transfer.
HMPPS
Scottish Fatal Accident Inquiries(1)
Article 2 learning points(5)
— LP 10
Doncaster Prison should develop a policy for relative/next of kin liaison in circumstances other than deaths in custody, including life-threatening situations.
The Governor
Accepted
— LP 8
We recommend that in conjunction with PECS, GEOAmey puts in place a procedure for a senior manager to be notified whenever a serious incident of illness or other harm occurs. The designated senior manager should take immediate responsibility for ensuring that families are notified at the earliest opportunity, facilitating access …
PECS and GEOAmey
Accepted
— LP 4
We recommend that stronger efforts are made to assemble and substantiate basic information about prisoners’ next of kin and family situation, particularly where young offenders are concerned.
HMPPS
Accepted
— LP 2
HMP Featherstone should review its procedures so that families are informed of a prisoner’s illness with a minimum of delay.
HMP Featherstone
Accepted
— LP 2
HMP Norwich should ensure that there is an awareness of the contents of property returned to prisoners next of kin, and that such returns are handled sensitively
HMP Norwich
PHSO casework decisions(58)
P-003131 — East Kent Hospitals University NHS Foundation Trust
Mrs B complained the Trust failed to contact her when her husband was hospitalised, preventing her involvement in care decisions and saying goodbye before his death.
NHS in England
Nov 2024
P-003374 — James Paget University Hospitals NHS Foundation Trust
Mrs A complained a consultant nephrologist failed to communicate effectively and discuss treatment options with her family during her husband's final hours, causing immense distress.
NHS in England
Feb 2025
P-004516 — East of England Ambulance Service NHS Trust
Mrs F complained the Trust and NHS 111 failed to contact next of kin, shared incorrect information, and had poor record keeping, which she believed led to delayed treatment and her father's death.
NHS in England
Dec 2025
P-002573 — Northern Care Alliance NHS Foundation Trust
Mr U complained the Trust delayed contacting him about his husband's deteriorating health, preventing him from being present at his death, and restricted visiting times.
NHS in England
Apr 2024
P-002983 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs H complained the Trust failed to timely diagnose her husband's cancer, poorly communicated his condition, did not prevent his escape, and inadequately informed her about tumour lysis syndrome.
NHS in England
Sep 2024
P-003387 — Royal Berkshire NHS Foundation Trust
Mr I complained about his wife's clinical care, lack of family communication, DNAR being signed without family present, and difficulties with the cause of death communication.
NHS in England
Feb 2025
P-003394 — London North West University Healthcare NHS Trust
Ms E complained the Trust wrongly removed her father's cardiac monitor, failed to treat sores and provide water, and did not notify her of his death, causing profound distress.
NHS in England
Mar 2025
P-003491 — South Tyneside and Sunderland NHS Foundation Trust
Mrs A complained the Trust ignored her husband's wish to be re-intubated and excluded her from discussions, leading to delays, infection, and his subsequent death.
NHS in England
Apr 2025
P-003479 — Isle of Wight NHS Trust
Mrs F complained Trust A failed to inform her of her husband's sepsis and transferred him without her consent. She also stated Trust B provided inappropriate care and delayed informing her of his death.
NHS in England
Apr 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-004641 — University Hospitals Coventry and Warwickshire NHS Trust
Mr B complained the Trust provided inappropriate treatment, caused care delays, discharged his father unsafely twice, and failed to communicate his father's end-of-life status to the family.
NHS in England
Partly Upheld
Jan 2026
P-001078 — South Central Ambulance Service NHS Foundation Trust
Miss E complained ambulance crew left her unconscious brother in the street without care, leading to his death. She also alleged the Trust handled her subsequent complaint poorly.
NHS in England
Jun 2021
P-001072 — Manchester University NHS Foundation Trust
Ms A complained her deceased brother’s NG tube was wrongly inserted, causing fluid to enter his lung and contributing to his death. She also alleged poor communication about his cardiac arrest and inconsiderate handling of tissue donation.
NHS in England
Upheld
Jun 2021
P-001103 — East of England Ambulance Service NHS Trust
Mr R complained the Ambulance Trust delayed his wife's ambulance for over four hours, contributing to her death, and also alleged hospital care failings.
NHS in England
Not Upheld
Aug 2021
P-001816 — Dartford and Gravesham NHS Trust
Mrs O complained King's College Trust failed to refer her father to A&E, and D&G Trust inappropriately discharged him and failed to communicate his deteriorating condition.
NHS in England
Feb 2023
P-002824 — University Hospitals Birmingham NHS Foundation Trust
The Trust allegedly kept Mrs G's mother in hospital unnecessarily, mismanaged her nutrition/hydration, failed to communicate deterioration, and made incorrect discharge record entries.
NHS in England
Jul 2024
P-002782 — Barts Health NHS Trust
The Trust allegedly mismanaged Miss F's mother's deterioration, prematurely withdrew treatment, and communicated poorly regarding a Do Not Attempt Resuscitation (DNAR) decision.
NHS in England
Partly Upheld
Jul 2024
P-003107 — University Hospitals Birmingham NHS Foundation Trust
Mr H complained his partner, Mrs I, was left alone with sepsis, fell, and broke her ankle. He also alleged the Trust failed to notify him of her admission or communicate, and delayed complaint responses.
NHS in England
Partly Upheld
Nov 2024
P-003111 — A practice in the Thurrock area
Mr A complained the Practice delayed a cancer referral for his father, leading to a late diagnosis. He also alleged the Trust poorly managed his father's pain and communication.
NHS in England
Nov 2024
P-003448 — East Sussex Healthcare NHS Trust
Miss B and Mrs B complained a nurse administered wrong medication, and the Trust delayed notifying the family of Mr B's deterioration, causing distress and affecting their grieving process.
NHS in England
Partly Upheld
Mar 2025
P-003567 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs X complained the Trust gave incorrect advice, preventing her from seeing her deceased brother before the mortuary, which caused significant distress.
NHS in England
May 2025
P-004262 — University Hospitals of Liverpool Group
Miss X complained about the University Hospitals of Liverpool Group's poor communication regarding her father's deteriorating condition, preventing her from spending valuable final moments with him.
NHS in England
Upheld
Nov 2025
P-004464 — University Hospitals Birmingham NHS Foundation Trust
Mrs O complained about her father's care, citing unclear DNACPR status, delayed CPR, unnecessary sedation, poor communication, and lack of dignity, believing these contributed to his death.
NHS in England
Dec 2025
P-004533 — Central London Community Healthcare NHS Trust
Mrs H complained the Trust's palliative care phone was unresponsive and text messages ignored, preventing her from getting emergency end-of-life support for her husband.
NHS in England
Dec 2025
P-004642 — Oxford University Hospitals NHS Foundation Trust
Ms M complained the Trust delayed her mother's radiotherapy, communicated poorly about disease progression, mismanaged her mother's belongings after death, and handled her complaint poorly.
NHS in England
Dec 2025
P-001061 — Royal Free London NHS Foundation Trust
Mr E complained ED staff repeatedly failed to diagnose and treat his arm/chest pain, ignoring prior visits and medical history, leading to a preventable heart attack.
NHS in England
Partly Upheld
Apr 2021
P-001058 — Maidstone and Tunbridge Wells NHS Trust
Miss S complained the Trust failed to reposition her mother, delayed MRI/surgery, communicated poorly with her family, and provided delayed, inconsistent complaint responses.
NHS in England
Partly Upheld
Apr 2021
P-001076 — University College London Hospitals NHS Foundation Trust
Dr I complained about inadequate postnatal care for his wife and daughter, citing delayed doctor attendance, insufficient pain relief, missed clinical follow-ups, inappropriate antibiotics, and unsafe discharge planning.
NHS in England
Not Upheld
Jun 2021
P-001384 — Northern Care Alliance NHS Foundation Trust
Ms O complained about poor nursing care and communication during her mother's last moments and inadequate handling of her subsequent complaint, which caused her significant distress and grief.
NHS in England
Mar 2022
P-002052 — County Durham and Darlington NHS Foundation Trust
Mr I complained the Trust delayed his mother's hip surgery, discussed risks without family present, restricted visits, and notified him of her death by text message.
NHS in England
Jun 2023
P-002390 — Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation …
Mr J complained about delays in his wife's checks and scans, poor communication about her diagnosis and transfer, and non-adherence to treatment advice, which he believes led to her death.
NHS in England
Jan 2024
P-002410 — Manchester University NHS Foundation Trust
Mrs C complained Manchester University NHS Foundation Trust had poor communication regarding her husband's deteriorating health, COVID-19 diagnosis, and impending death.
NHS in England
Jan 2024
P-002431 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs I complained Ashford and St Peter's Hospitals NHS Foundation Trust failed to discuss her husband's CT scans, explain his condition or why surgery wasn't possible.
NHS in England
Jan 2024
P-002433 — University Hospitals of North Midlands NHS Trust
Mrs X complained she was not allowed to accompany her husband to A&E or discuss his symptoms, causing a stroke diagnosis delay and worsening his condition.
NHS in England
Partly Upheld
Jan 2024
P-002464 — Birmingham Women's and Children's NHS Foundation Trust
Miss E complained about numerous care failings after her daughter's stillbirth, including poor monitoring, communication, and hygiene.
NHS in England
Feb 2024
P-002481 — Royal Free London NHS Foundation Trust
Miss R complained the Trust failed to resuscitate her newborn son, Baby R, in June 2021, alleging his death was avoidable due to the Trust's actions.
NHS in England
Feb 2024
P-002740 — Manchester University NHS Foundation Trust
Mr I alleged his father was prematurely discharged, not monitored for Sarilumab side effects, and communication was poor, contributing to his death.
NHS in England
Partly Upheld
Jun 2024
P-003069 — The Princess Alexandra Hospital NHS Trust
Mrs W complained about a delayed CT scan, missed AF diagnosis, lack of family contact when her father deteriorated, being misled, and incorrect causes of death on his death certificate.
NHS in England
Oct 2024
P-003093 — East Suffolk and North Essex NHS Foundation Trust
Miss O complained the Trust failed to treat her sister quickly, placed her inappropriately, mismanaged hydration and oxygen, neglected posture, and did not involve family in critical treatment discussions before her death.
NHS in England
Partly Upheld
Oct 2024
P-003175 — East Suffolk and North Essex NHS Foundation Trust
Miss R complained the Trust administered morphine to her mother despite knowing of an allergy, provided poor emergency care, and believed it caused her mother's death.
NHS in England
Nov 2024
P-003234 — Tameside and Glossop Integrated Care NHS Foundation Trust
Miss G complained the Trust delayed acting on Mr H's lung disease diagnosis, preventing treatment, and failed to notify his brothers of risks, contributing to his death.
NHS in England
Partly Upheld
Dec 2024
P-003380 — Portsmouth Hospitals University NHS Trust
The Trust allegedly missed opportunities to admit Mr C, failed to prevent a pulmonary embolism, and an injection caused his sudden death in November 2021.
NHS in England
Feb 2025
P-003397 — Buckinghamshire Healthcare NHS Trust
Mr E complained about poor care and treatment, including delayed admission, inappropriate medical care, and poor communication during his wife's hospital stay, which he believed contributed to her death. He also criticised the Trust's complaint handling.
NHS in England
Mar 2025
P-003720 — Royal Papworth Hospital NHS Foundation Trust
Mr V complained the Trust did not allow his mother's belongings, repeatedly attempted morphine against her wishes, failed to prevent the family seeing her deceased without warning, and inaccurately described her.
NHS in England
Jul 2025
P-003813 — South Tyneside and Sunderland NHS Foundation Trust
Mrs A alleged the Trust ignored her husband's wishes for re-intubation, failed discussions, used a nurse for extubation, and delayed extubation leading to infection and his death.
NHS in England
Aug 2025
P-003804 — Warrington and Halton Hospitals NHS Foundation Trust
Mr A complained the Trust failed to monitor his father's post-operative condition and escalate concerns, leading to his death. He also alleged poor communication with his mother.
NHS in England
Aug 2025
P-003800 — West London NHS Trust
Mr L complained the Trust failed to appropriately assess and manage his daughter's risk, and communicate effectively, leading to her taking her own life.
NHS in England
Aug 2025
P-004034 — Isle of Wight NHS Trust
Mrs F complained about the Trust's decision to move her father from ICU, his subsequent monitoring, circumstances surrounding his cardiac arrest, and poor communication, believing his death was avoidable.
NHS in England
Sep 2025
P-004164 — Oxford University Hospitals NHS Foundation Trust
Dr K complained about his son's surgical care, including lack of consent, poor monitoring, communication failures, and delayed resuscitation, which he believes led to his death. He also cited delays and errors in the Trust's investigation.
NHS in England
Oct 2025
P-004290 — University Hospitals Birmingham NHS Foundation Trust
Complaint alleged a Trust failed to identify and act on her father's deterioration and did not communicate this to the family, exacerbating their grief.
NHS in England
Nov 2025
LGO / SPSO decisions(3)
24-001-037 — Southampton City Council
Summary: There was fault in the Council’s actions as the Council failed to take all the appropriate action when an emergency call was made and did not let Mrs C know that it had called an ambulance for her mother. The Council has agreed to apologise, pay a financial remedy …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
22-000-748 — London Borough of Newham
Summary: Mrs X complained about the Council’s refusal to cancel a PCN due to a medical emergency. We have not found the Council to be at fault. It considered Mrs X’s circumstances but decided not to cancel the PCN. This was a decision the Council was entitled to make.
LGO (Local Government & …
Transport And Highways
Not Upheld
Sep 2022
NIPSO-201916450 — South Eastern Health and Social Care Trust
The South Eastern Health Trust failed to tell a man about changes to his mother’s nutritional plan and the process of her palliative care.
NIPSO (NI Public Service…
Health & Social Care
Feb 2023