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 17 independent accountability sources, so the source mix matters as much as the headline total.
17 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
15 DHR recs
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(17)
92 — Casualty bureaux procedures
Recommendation: Casualty bureaux procedures should be reviewed in order to ensure that they remain open for as long as required and that adequate telephone facilities are available (para 2.24).
Unknown
91 — Faster identification of victims and release of information
Recommendation: Identification of victims should be speeded up and information released to relatives at the earliest possible time (para 2.24).
Unknown
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.
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
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: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F174 — Candour about harm
Recommendation: Where death or serious harm has been or may have been caused to a patient by an act or omission of the organisation or its staff, the patient (or any lawfully entitled personal representative or other authorised person) should be …
Gov response: Accepted. The Secretary of State for Health legally required NHS England to insert a contractual duty of candour into the NHS Standard Contract in 2013–14. This means that NHS Trusts and Foundation Trusts are contractually …
Accepted
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 National Major Crime Investigation Manual (MCIM 2021) details the separate roles of SIO and FLO which have their own distinct and individual strategy. - Review of FLO deployments completed and no cases of …
Accepted
Prevention of Future Deaths reports(113)— showing 50 strongest matches
Derek Edward Bartlett Twivey
Concerns: The coroner noted that a falls risk assessment for a patient with a known high falls risk was not conducted within the anticipated 24 hours of arrival at a nursing home, due to it being a weekend and staffing pressures.
Overdue
Annie Rose Gibson
Concerns: The report raises concerns for Saga Homecare regarding the circumstances surrounding the death of an 84-year-old lady who had fallen while receiving daily home care.
Overdue
Clive Gould
Concerns: The coroner raised concerns regarding the ambulance service's call priority allocation, which led to diversions, and insufficient system resilience, particularly in rural areas. Additionally, communication with callers about estimated arrival times and potential delays was identified as needing review.
Response (South Central Ambulance Service): • SCAS stated it was transitioning to the NHS Pathways system for call priority allocation, with completion expected by the end of autumn 2014. • Rapid Response Vehicle cover was … (AI summary)
Responded
Christopher James Morgan
Concerns: The coroner raised concerns regarding the lack of communication with family and carers before changing a patient's risk level for leave, and the absence of a clear policy on staff-to-patient ratios for escorted leave from psychiatric wards.
Overdue
Daniel Maurice McMahon
Concerns: The coroner identified gaps in the Metropolitan Police's gathering of precise location information for railway trespassers and raised concerns about the RSSB Rule Book, suggesting it require trains to stop when an unwell person is on the line.
Response (Response R): • The London Ambulance Service (LAS) reviewed its practice regarding the use of one-way valves on needle chest decompressions. • The LAS concluded that its current approach, which does not … (AI summary)
Response: • The Department of Health stated it is reviewing the advice in the Code of Practice Mental Health Act 1983. • This review includes the chapter on leave of absence … (AI summary)
Overdue
James Stokoe
Concerns: A lack of formal consultation with carers or partners of mental health service users limits comprehensive risk assessment, especially for domestic abuse involving the elderly. Concerns were also raised about ensuring locally learned lessons are shared nationally.
Overdue
Noel Williams
Concerns: The coroner noted a failure to communicate recent haemoglobin test results to the anaesthetist and surgeon, which was important for assessing the patient's fitness for surgery. This gap in communication could lead to future deaths.
Overdue
Jean James
Concerns: The coroner identified delays in initial documentation, an unreviewed omission of prophylactic Dalteparin, and ineffective communication of a pharmacy query. Concerns were also raised that existing systems and policies may not be robust enough to manage human factors.
Response (City Hospitals Sunderland): • The Trust reviewed its hospital information system (MEDITECH V6) and is implementing updates to automatically prompt VTE medication prescriptions and alerts. • The Trust introduced a new patient-focused format … (AI summary)
Responded
Charles Bradley
Concerns: The coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
Overdue
Christopher Williams
Concerns: The defibrillator machine was inoperable and had not been checked daily as required. There was no cross-check system or policy for the management of sudden unexpected deaths in place at the hospital.
Overdue
Robert Jones
Concerns: The coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Response: • The Health Board stated it would ensure CT scan results are made available promptly and routinely monitored. • The Radiology department will undertake sampling of scan-to-report times for emergency … (AI summary)
Responded
Caroline Pilkington
Concerns: North West Ambulance Service personnel are not trained in control and restraint techniques, leading to calls for police assistance with unwell patients. This can result in clinically unwell patients being handled by non-clinically trained police and delays in hospital transport.
Response (Greater Manchester Police): • Greater Manchester Police's revised officer safety training programme emphasizes recognizing medical risks and treating situations as medical emergencies. • Greater Manchester Police offered to support North West Ambulance Service … (AI summary)
Response (North West Ambulance Service NHS Trust): • North West Ambulance Service (NWAS) stated that advanced control and restraint training for its staff is not feasible or safe due to the specialised nature of the skill and … (AI summary)
Response (Department of Health): • The Department of Health noted the existence of a joint protocol, established in March 2012, between North West Region Police Forces and NWAS for inter-agency working regarding patients requiring … (AI summary)
Response (Department of Health2): • NWAS confirmed that a regional protocol with police forces is in place and under review. • NWAS presented the inquest findings at the North West Police Regional Mental Health … (AI summary)
Responded
Graham Watts
Concerns: The coroner noted significant flaws in Mr. Watts' hospital discharge procedure, including blank paperwork, a lack of communication with his nursing home and family, and his medical unsuitability for discharge. He returned to the nursing home in a deteriorated state.
Response (Brighton Sussex University Hospitals NHS Trust): • Senior nursing staff confirmed they had emphasized the importance of completing a nurse-to-nurse discharge summary for patients returning to residential or nursing home care. • The Trust is devising … (AI summary)
Responded
Terence Dooley
Concerns: The coroner noted concerns regarding the inappropriate green coding of an emergency overdose call, resulting in a significant delay in ambulance response. Gaps in communication and misleading computer-generated codes were identified as contributing factors.
Response (North West Ambulance Service NHS Trust): • North West Ambulance Service (NWAS) confirmed that an audit of the call determined the Green 2 code was correct based on the Medical Priority Dispatch System (MPDS). • NWAS … (AI summary)
Responded
Alun Sheppard
Concerns: The coroner raised concerns regarding the Health Board's ability to balance a patient's right to confidentiality with the potential benefits of facilitating familial support to optimize recovery.
Response (NHS Wales): • The Health Board stated that mental health practitioners routinely encourage service users to engage with family members and increase support networks. • The Health Board confirmed its policy is … (AI summary)
Responded
Marion Turner
Concerns: A message from Ms Turner's solicitor about her mental health concerns was left for her CPN but remained unread until the next day, indicating a delay in processing important patient information.
Overdue
Silvia Taylor
Concerns: Unsuccessful attempts to contact Mrs. Taylor were not acted upon for several hours, and these difficulties were not conveyed to her family. The coroner suggests reviewing 'no speech call procedures' for after-hours support.
Response (Care UK): • Care UK reviewed and updated its policy regarding procedures for unsuccessful telephone contact with patients. • The updated policy addresses scenarios for patients requiring further telephone assessment or a … (AI summary)
Overdue
Joshua Brown
Concerns: The coroner noted limited information sharing with Mr. Brown's parents, his primary support, due to his wishes and their non-carer status, which impacted their ability to assist the team. There was also no system for family members to review and confirm the accuracy of notes made by the community team.
Response (Department of Health): • The Department of Health facilitated and published a consensus statement on confidentiality, information sharing, and suicide prevention in January 2014. • The consensus statement advises practitioners to discuss information … (AI summary)
Overdue
Graham Darby
Concerns: A specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
Overdue
Roseanne Cooke
Concerns: The coroner noted a lack of inpatient psychological support and confusion regarding outpatient referrals. Concerns were also raised about the Recovery Team's attendance at discharge meetings and insufficient communication of family concerns about the deceased's suicidal thoughts to the team.
Response (5 Borough Partnership NHS): • The Trust produced an action plan to improve the process for managing extended leave, including reviewing psychology provision and ensuring detailed electronic record entries. • The Borough's Leadership Team … (AI summary)
Responded
Simon Satchwell
Concerns: The coroner identified a disparity in jet ski safety regulations for minors between the UK and the UAE, where a 14-year-old died unsupervised. Concerns were raised regarding clearer travel advice for British nationals about differing local safety standards for activities involving children.
Overdue
Colin Tyson
Concerns: The coroner noted concerns regarding GPs' interpretation of patient confidentiality, which prevented family members from sharing pertinent information about vulnerable individuals at risk.
Response (NHS England): • NHS England, in collaboration with NHS Wakefield Clinical Commissioning Group, developed an advice sheet for GP practices on responding to third-party concerns or information requests about patients. • This … (AI summary)
Responded
Archie Hexall
Concerns: The coroner noted a breakdown in communication between midwives regarding signs of respiratory distress, and the initial observation records were not retained. Parents were also not informed of concerns about their child's breathing, limiting their opportunity to contribute to care.
Response (Lewisham Greenwich NHS Trust): • Staff have been reminded that all loose documentation must be secured into the main clinical notes. • The Trust is embedding the SBAR communication tool within the maternity service, … (AI summary)
Responded
Margaret Wright
Concerns: The coroner noted that doctors did not routinely telephone patients or their families when a home visit was requested to obtain further information, which could have led to a priority visit in this case. A system for pre-visit telephone contact has since been introduced and should be drawn to the attention of the Secretary of State for Health.
Response (Department of Health): • The GP practice concerned and in the local area introduced a system of phoning patients or family members after a home visit request. • NHS England's Primary Care Patient … (AI summary)
Responded
Julia Hayward
Concerns: Care plans for patients discharged into the care of family members following mental health assessments are agreed orally and not documented for the family, leading to uncertainty about responsibilities.
Response (Department of Health): • The Department of Health stated that the 1983 Code of Practice requires care plans to be clearly documented and provided to patients and carers. • The Department of Health … (AI summary)
Responded
William Abel
Concerns: A Mental Health Act assessment was not conducted when Mr. Abel expressed suicidal intention, and there was inadequate communication with his family about his mental health relapse and the expectation for his safe keeping.
Response (Leicester Partnership NHS Trust): • The nurse concerned is undergoing a programme of reflective practice. • The protocol for Mental Health Act assessments by the Triage Car service is being revised, and changes have … (AI summary)
Responded
Frank Mellers
Concerns: The coroner noted the patient's DNAR status was fixed without family discussion, contrary to good practice. There was poor communication between nursing and medical staff, leading to a resuscitation attempt despite a DNAR order.
Response (Frank Mellers): • The organisation reiterated the importance of daily ward rounds and developed a Ward Board indicator to highlight DNAR status to all staff. • The DNAR policy was reviewed to … (AI summary)
Overdue
Edna Cleaton
Concerns: The practice lacked systems to ensure patients on citalopram received appropriate medical reviews every 3-6 months, as one patient went over 3 years without review, potentially missing signs of deterioration.
Response (Edna Cleaton): • The practice stated that repeat prescriptions for antidepressants are issued for a maximum of six months, requiring a review thereafter. • The practice confirmed the existence of a repeat … (AI summary)
Responded
Joanne French
Concerns: Insufficient clarity and communication regarding early patient discharge assessment requirements were noted, along with unclear documentation. Additionally, there was no process for family members, who would provide care, to input their views or understand the discharge decision.
Overdue
Brenda Morris
Concerns: The coroner noted insufficient communication with a patient's partner regarding the basis for weekend leave and a lack of routine family feedback post-leave. There were also concerns about confusion over medical authorisation for informal patient leave and substandard nursing documentation.
Response (East London NHS Trust): • The Trust developed an 'Informal patient leave agreement' template requiring doctor authorisation, detailing leave conditions, and signed by the doctor, patient, and relative. • The Trust developed an 'In-patient … (AI summary)
Responded
Patricia Medland
Concerns: The deceased's daughter was unaware of her designated role as a protective factor in her mother's care plan, which limited her ability to recognise signs of mental health relapse.
Response (Brampton Surgery): • The Practice agreed that the sharing of appropriate information with nearest relatives and carers should be encouraged and stated it would always discuss this with the patient. • The … (AI summary)
Responded
Lisa Day
Concerns: Alternative hospital transport options were not discussed with the friend who called 111, and the potentially grave consequences of a vomiting illness in a person with diabetes were not explained to him.
Response (Lisa Day Response2): • The London Ambulance Service (LAS) and NHS 111 agreed a process for 111 clinicians to alert LAS Emergency Operations Control about calls with clinical concerns. • An electronic flagging … (AI summary)
Response (Lisa Day): • London 111 providers agreed to amend the memorandum of understanding with London Ambulance Service to require clinicians to discuss self-conveyance options and risks with patients and callers during periods … (AI summary)
Responded
Mandeep Singh
Concerns: The coroner noted severe demand and staff shortages within the North East Ambulance Service division contributed to ambulance arrival delays, further impacted by road closures and diversions.
Response (North East Ambulance Service): • The Trust has implemented initiatives to manage demand, including public education campaigns and a trial scheme with Fire and Rescue Services for Emergency Medical Responders. • The Trust has … (AI summary)
Responded
Monica Lewis-Hinds
Concerns: The London Ambulance Service's call triage protocol does not require call handlers to explicitly ask about the "type of fit," only completing the section if the caller offers the information, which the coroner suggests may need amendment.
Overdue
Jack Susianta
Concerns: The consultant psychiatrist did not communicate clear clinical expectations to Jack's family before discharge, including what recurrence of psychotic symptoms would signify and when to seek urgent professional help. This left the family unaware of when immediate re-hospitalisation might be necessary.
Overdue
Samuel Carroll
Concerns: Concerns were raised regarding police and ambulance services not seeking Mr Carroll's consent to inform family or friends about his suicidal ideation and hospital admission. Consequently, no one was alerted to him being taken to or discharged from the hospital.
Response (Yorkshire Ambulance Service): • The service stated it is standard practice for clinicians to ask patients if they wish for family members to be contacted during a welfare assessment. • Next of kin … (AI summary)
Response (North Yorkshire Police): • A Mental Health Awareness training programme was delivered to 200 officers in May 2016 and is scheduled for roll-out to remaining staff in 2017/18. • The training will include … (AI summary)
Responded
James Flynn
Concerns: The coroner identified inadequate discharge planning for an unwell, elderly diabetic patient, who was sent home late without a detailed care plan, family notification, or provisions.
Overdue
Charles Woodward
Concerns: Inadequate communication and liaison between the hospital, GP practice, and district nurses regarding the deceased’s ongoing care post-discharge. Additionally, monitoring of the deceased’s condition from the hospital was not robust enough, and there was miscommunication with the family about the deceased's declining health.
Overdue
Georgina Lewis
Concerns: The coroner noted a lack of family notification or consultation in the discharge decision, the absence of a discharge plan or follow-up support, and no contemporaneous notification of the discharge to Mrs Lewis's GP.
Overdue
Emily Voukelatou
Concerns: The coroner noted that the crisis team did not routinely involve family members in patient care, potentially losing valuable input. Additionally, a patient's family members made repeated unreturned calls to Crisis House, resulting in lost information and increased anxiety.
Response (Camden and Islington NHS Trust): • The Trust reinforced the importance of working with families in its updated risk assessment training, which has been rolled out over the last 12 months to nearly 500 staff. … (AI summary)
Responded
Debrata Sircar
Concerns: The coroner noted delays in securing a bed and conducting a Mental Health Act assessment for a patient needing hospitalization, due to unavailability of a local authority practitioner. There was an absence of an interim care plan and a lack of clarity regarding psychiatric monitoring during this period.
Response (Oxleas NHS Foundation Trust): • The Trust has implemented a practice to rezone clients referred for a Mental Health Act (MHA) assessment to 'Red' until the assessment is completed. • Referrals to the Home … (AI summary)
Overdue
Doreen Stapleton
Concerns: The coroner noted insufficient emphasis on discharge advice, specifically the lack of explicit communication to the patient and family about the critical importance of follow-up medication and the absence of a contact number for the district nursing team.
Response (Whittington Health NHS): • The Trust stated that its Director of Nursing and Executive Medical Director would write to doctors, senior nurses, and pharmacists to highlight key learning points. • The Trust reported … (AI summary)
Responded
Mariana Pinto
Concerns: The coroner identified insufficient communication to the family about crisis team limitations and anticipated illness progression. An urgent crisis line call did not result in the nurse suggesting or making an emergency call, or considering an earlier home visit.
Response (response Pinto): • A written discharge care plan is being developed and will be implemented to clarify crisis team limitations and advice on symptom resurgence. • The Home Treatment Team (HTT) will … (AI summary)
Responded
John Ramsden
Concerns: Concerns were raised that not all of John Ramsden's daughters were consulted about his end-of-life care and decisions regarding hospital admission for treatment.
Overdue
Rasikaben Chauhan
Concerns: The coroner noted a lack of clarity regarding whether awareness about a specific risk had been raised at local or national levels with relevant community and religious organisations.
Response (Northampton County Council): • Northamptonshire Fire and Rescue Service (NFRS) made the risks and circumstances of the death known to other UK Fire Services via a national communication tool. • NFRS delivered specific … (AI summary)
Overdue
Barbara Sturgess
Concerns: The Chesterfield Royal Hospital did not promptly inform the nursing home or GP of a patient's cervical spinal fracture or necessary care measures, with formal confirmation only provided after nursing home enquiries. This communication gap had the potential to adversely affect wellbeing.
Overdue
Melvin James
Concerns: The patient was discharged from hospital while still experiencing delusions, with the clinician unaware of the family's observations. There was insufficient communication with the family about relapse symptoms and no formal referral or aftercare arranged with mental health services post-discharge.
Overdue
Conall Gould
Concerns: The coroner raises concerns about the lack of clear communication to patients and their carers regarding follow-up mental health appointments after discharge. There is no formal policy or protocol requiring notification or written confirmation of these arrangements, increasing the risk of missed appointments and lost opportunities for patient review.
Response (Conall Patrick): • The Trust introduced a requirement for all discharged patients to receive written confirmation of their follow-up appointment, including contact numbers. • The protocol directs that a patient-identified carer will … (AI summary)
Responded
Gillian O’Keefe
Concerns: The coroner identified an illogical discharge decision despite mental health deterioration, an absence of pre-discharge meetings with the GP, and no policy for urgent GP referrals. Difficulties for the family to communicate concerns were also noted.
Response (South West London and St Georges Hospital NHS Trust): • The Clinical Disengagement/Did Not Attend Policy has been updated to include more prescriptive actions before patient discharge, such as GP engagement. • The Trust will re-enforce to staff the … (AI summary)
Response (Department of Health): • The South West London and St George's Mental Health NHS Trust will update its clinical disengagement/did not attend policy to be more prescriptive regarding actions and stakeholder engagement during … (AI summary)
Responded
Ryan Vout
Concerns: The coroner identified insufficient co-ordination in discharge planning from inpatient psychiatric care, including a lack of liaison between professionals and family. Concerns were also raised about the inability to pre-arrange ambulances and the informal nature of risk assessments before executing MHA warrants.
Response (Nottinghamshire County Council): • The issue of improving ambulance provision for Mental Health Act work has been escalated and discussed with health commissioners. • The Crisis Concordat Task and Finish Group is exploring … (AI summary)
Response (East Midlands Ambulance Service NHS Trust): • East Midlands Ambulance Service (EMAS) stated that the ability to pre-book an ambulance for Section 135 or 136 Mental Health Act warrants has always been available. • The Trust … (AI summary)
Response (Department of Health): • The Department of Health noted the coroner's concerns regarding discharge planning and the conveyance of patients under the Mental Health Act. • The government commissioned an independent review of … (AI summary)
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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Acknowledged
#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 attribution not verified
#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 …
Response attribution not verified
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
Health investigations(66)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (ix)
The Trust and Council should ensure that details of the contingency plan and crisis plan are made known to carers of the service user and any other persons who are voluntarily involved in the monitoring process and that they are provided with defined channels of communication to the mental health …
london
Independent investigation: Michael Kahan, Manchester (2008) — Rec 10
The Trust should ensure that it complies with policy in relation to contact, information sharing and support to carers after a Serious Untoward Incident.
north_west
Independent investigation into the care and treatment of Mr X — Rec 16
Following serious incidents involving homicide or suicide the Trust must make every effort to contact families with immediate effect. The Trust and NHS England should discuss how best this can be facilitated (in light of the new arrangements set out directly above) with the Metropolitan Police Service and ensure that …
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 6
The Trust should develop guidance on when contact with relatives/partners becomes essential as part of the care of patients. This is particularly needed when patients fail to engage yet are clearly ill and, when safeguarding criteria for doing so without the patient’s permission are reached.
north_west
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 37
We recommend that the AWOL policy should require that next of kin/carers be given advice about what to do if they locate the patient, and given a specific contact point or communication channel for use in such circumstances, and for more general contact regarding the AWOL situation.
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 26
We recommend that the Leave Policy should contain provisions requiring staff to inform the patient and carer/family about crisis and contingency planning in the event that something goes wrong during the period of leave. Staff should also provide a point of contact where the carer/family members can avail of advice.
northern_ireland
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 15
Hertfordshire Partnership NHS Foundation Trust should ensure that one of the functions of the Incident Co-ordination Group is to devise and agree a communications plan to ensure that communication with applicable and appropriate service users and their families are co-ordinated and timely.
east_of_england
Independent investigation: Robert Lewis, Sutton (2010) — Rec Five
It is recommended that in cases where individuals with mental illness commit a serious crime causing the death of another that the police consider appointing a family liaison officer to support that person’s immediate family.
london
Independent investigation: Robert Lewis, Sutton (2010) — Rec Three
It is recommended that following a serious incident such as a homicide a senior manager from the Trust is designated to provide support and information to the family. It is further recommended that the implementation of this recommendation be monitored by regular audit reporting to the Trust’s Clinical Governance Committee.
london
Independent investigation: Robert Lewis, Sutton (2010) — Rec Two
It is recommended that following a serious incident such as a homicide by an individual receiving mental health services that the Trust’s responsibilities are aligned to the expectations set out within the Department of Health guidance HSG (94) 27 and their duty of care. This would ensure that families of …
london
Independent investigation: Peter Freeman, Newton Abbott (2019) — Rec Recommendation Eight
The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved in the investigation.
south_west
Independent investigation: Melanie Welch (Ms B), Redhill, Surrey (2001) — Rec 7.1
We recommend that Surrey Oaklands NHS Trust reviews its ‘Incident Management Policy’ to ensure that:- A senior manager is designated to provide support and information to families following a serious untoward incident and guidance is provided for anyone undertaking the role. Staff involved in serious untoward incidents provide written statements …
south_east
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 4
The DHSSPS and the Boards should instruct Trusts to draw up and implement policies regarding consultation by staff with patients’ families during an in-patient stay, in particular at admission, discharge and where the patient has a dependent child or children.
northern_ireland
Independent investigation: Karen Godden, Leicester (2007) — Rec 5
Although the internal investigation team did meet with the family of this MHSU during the course of its investigation, there was no immediate post incident support provided to the family by the MHSU’s care team. Neither was any support offered to the family of Miss K. Today LPT has a …
midlands
Independent investigation: Jayne Poppy, Leigh on Sea (2002) — Rec 13
The Trust should ensure that there is a system in place for ensuring that the telephone numbers given to relatives and lay carers for use in an emergency are local to the patient's place of residence.
east_of_england
Independent investigation: Hamidi HamidullahKhizer Hayat, Tulse Hill (2006) — Rec Recommendation Numbe
The Trust should develop strategies to ensure that condolences, support and advice are offered to the families / loved ones of the victims of homicide without this endangering the police investigation and judicial processes.
london
Independent investigation: Elizabeth Cook, Langley, Berks (2006) — Rec 2
Steps should be taken to ensure that family members in close contact with a service user on standard CPA are made aware of the existence of the Crisis Resolution Service, and how to access it.
south_east
*Mental health homicide investigation legacy report into the care and … — Rec 4
The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way. This must extend to retaining contact details for key family members of …
south_east
Independent Investigation into the care and treatment provided to Mr … — Rec 9
The Trust should ensure that the families of all victims of homicide perpetrated by service users receiving care and treatment from the Trust are managed in keeping with NHS England expectation. Families should be: communicated with as soon as the homicide is made known to the Trust; offered …
south_east
An independent mental health homicide investigation into the care and … — Rec 13
AWP and Cygnet Health Care should consider recruiting a family liaison officer, who would be the single point of contact and provide support for families throughout the serious incident investigation process.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent investigation into the care and treatment of Mr … — Rec 2
The Trust must ensure that there is a defined process for ensuring that the Family Liaison Lead keeps affected parties up to date regarding progress of serious incident investigations.
south_east
An independent investigation into the care and treatment of Mr … — Rec Recommendation Eight
The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved in the investigation.
Devon Partnership NHS Trust
south_west
An independent investigation into the care and treatment of a … — Rec 9
The Trust should change the policy and procedure on engagement with and support of families of victims and perpetrators involved in serious incidents to comply with current guidance. This should include the requirement to document decisions made, and clear descriptions of roles and responsibilities.
south_east
An independent investigation into the care and treatment of a … — Rec R2
Discussions with relevant staff to take place around the decision not to contact the Nearest Relative and action implemented if indicated.
Cornwall Partnership NHS Foundation Trust
south_west
*Independent investigation into the care and treatment of Mr X: … — Rec 7
The Trust should ensure that one of the functions of the Incident Co-ordination Group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way.
east_of_england
*Independent investigation into the care and treatment of Mr A: … — Rec 15
Hertfordshire Partnership NHS Foundation Trust should ensure that one of the functions of the Incident Co-ordination Group is to devise and agree a communications plan to ensure that communication with applicable and appropriate service users and their families are co-ordinated and timely.
Hertfordshire Partnership NHS Foundation Trust
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 19
That, following production of the new leaflet which it is proposed should be available to the families of victims of homicides, the Trust implements a staff training programme which takes account of the sensitive nature of providing support to bereaved families; and that the voluntary sector be involved in, or …
midlands
Independent investigation: Richard Marden, Towcester (1999) — Rec 17
That where the need for an external independent inquiry arises, the Trust should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. This individual should be responsible, amongst other things, for: (a) keeping the family informed and up to date …
midlands
Independent investigation: Michael Kahan, Manchester (2008) — Rec 16
The Trust should ensure that investigations following serious untoward incidents follow the Trust policy. In particular the Trust should ensure that: staff and relatives are involved and informed in line with the principles of the policy; and that learning is disseminated to both staff and relatives.
north_west
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 20
that the trust and the social services authority devise simple procedures which ensure that, when a person in contact with either service commits homicide, the needs of the immediate family of both the deceased and the patient are ascertained, and they are supported; and that this includes offering support from …
south_east
Independent investigation: Steven Janczuk, Arlesey, Beds (2006) — Rec 8
The Trust should communicate with the victim’s and service-user’s families immediately following an incident to offer condolences, explain the Trust’s investigative processes and where appropriate offer an apology and provide support options. The Trust should consider, where contact with the family has not been established, that action is taken to …
east_of_england
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 35
We recommend that the AWOL policy should be clear that the Nurse-in-charge at the time of an AWOL ‘event’ is responsible for arranging the immediate actions under the policy (organising a search, informing the senior nurse, (whether on-site or on-call) SHO, next of kin/carers, assessing risk and informing the PSNI. …
northern_ireland
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 21
The trust should communicate with the victim‟s and perpetrator‟s families immediately after an incident to offer condolences, explain the trust‟s investigative processes and, if appropriate, offer an apology and support. (II/DB/AA)
london
Independent investigation: Ms B, Cheltenham (2008) — Rec 4
The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way.
south_west
Independent investigation: Leanne Unsworth, Burnley (2019) — Rec 3
The Trust should ensure that all service users (and their families/carers) are fully involved in their care and treatment planning, including diagnostic discussions. Information should be provided in an accessible format and language.
north_west
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 28
DHSSPS and Boards should ensure that Trusts have a policy in relation to identifying and recording ‘Next of Kin’ information. Trusts should also consider the extent to which staff training and/or refresher training should be provided for front-line staff involved routinely in taking personal history details from patients, particularly in …
northern_ireland
Independent investigation: John Hall, West Rainton (2013) — Rec 4.11.2
The trust should have a clear process in place to locate and engage the families of any victim’s so they have the opportunity to be supported and involved in the trust internal investigation. As a minimum the trust should ensure that the victim’s family: are provided with and consulted …
north_east_yorkshire
Independent investigation: Halimah Ahmed, Derby (2007) — Rec Nine
The Trust Being Open Policy should be revised to incorporate a specific section which offers direct guidance to staff regarding the communication and support that should be offered to both victim and perpetrator families following a homicide committed by a mental health service user known to the service.
midlands
Independent investigation: Elizabeth Cook, Langley, Berks (2006) — Rec 1
Standard CPA cases should be reviewed to identify any cases where the service user lives with a family member and has a history including psychotic episodes and risky behaviour; where this applies, consideration should be given to reviewing whether the CPA level is appropriate and whether there has been adequate …
south_east
Independent investigation: Chris Poole, Eastbourne (2012) — Rec 6
Following a serious incident such as a homicide, the Trust should incorporate best practice guidance available, including the Memorandum of Understanding that exists between the Department of Health, the Association of Chief Police officers and the Health and Safety Executive. This would ensure that timely contacting with victim and perpetrator’s …
south_east
Independent review of mental health treatment and care provided in … — Rec 2
Our team recommends that Dorset Healthcare should provide an opportunity for representatives from Colin’s family to meet representatives from the service to consider the circumstances of his death, understand the changes described in the report, and the ways in which recommendations will be acted upon.
south_west
Independent investigation into the care and treatment of Mr J — Rec R3
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area through the Trust serious incident action plan group. Feedback from the family for the purposes of this review suggests that information for carers should include Section 17 leave and we …
Mr J who committed a homicide in 2014. Mr J was in receipt of services from East London NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Mr … — Rec 13
The Trust must ensure that communication from families is logged appropriately and that a timely response is given. The Trust must also ensure that information is given to carers indicating what other routes are available to them if they are not satisfied that their concerns are being taken seriously.
south_east
An independent investigation into the care and treatment of Mr … — Rec 1
The Trust must ensure that communications with families use plain English and that when information cannot be provided there is an honest and clear rationale.
south_east
Independent investigation into the care and treatment of Mr J — Rec R3
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area through the Trust serious incident action plan group. Feedback from the family for the purposes of this review suggests that information for carers should include Section 17 leave and we …
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Accepted
Independent investigation into the care and treatment of DO — Rec 12
The Independent Investigation Team recommends a Trust faced with a similar situation in future must treat the families of victims as individuals. As a result, the Trust must acknowledge the personal knowledge levels of the case itself. The Trust must review its ‘Being Open Policy’ with a view to include …
DO who committed a homicide in 2013. DO was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Ms … — Rec 6
1. The Independent Investigation Team would encourage the Trusts involved in Ms K’s care at the time to consider reviewing the approach which they adopt in providing the families of those involved in incidents such as the death of Mr Edeson with information and support. 2. The Trusts review their …
north_east_yorkshire
An independent investigation into the care and treatment of Christie … — Rec 21
TEWV should review the Duty of Candour Policy and ensure that it is monitored through the relevant Board subcommittee processes. As part of this it must ensure that where there has been a death in a service, whether through self-harm/suicide or homicide, that families are given appropriate meaningful and regular …
An independent investigation into the care and treatment of Christie at Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of a … — Rec 5
The Trust should seek to agree with the police how and when it can engage with families who have been affected by a mental health homicide.
An independent investigation into the care and treatment of a mental health service user Ms C in Humber Teaching NHS Foundation Trust
north_east_yorkshire
Independent investigation: Richard Marden, Towcester (1999) — Rec 18
That in the event of a Serious Untoward Incident, contacts with and offers of support to the victim's family, including telephone contacts, should be documented and recorded in the Serious Untoward Incident report sent to the Health Authority. Details of contacts and offers of support made subsequent to the preparation …
midlands
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
Independent reviews(9)
Harris Review: Deaths in Custody — Rec 51
All custodial establishments should have in place a process that will ensure that all prisoners will be able to contact a family member or a friend within 2 hours of their arrival in Prison, including following a transfer.
Justice & Legal
Kerslake Review — Rec 42
Greater Manchester Police’s practice of extending the deployment of Family Liaison Officers to those who were severely injured should be considered for adoption by other Police Forces, if such an arrangement is not already in place
Policing & Security
Accepted
Angiolini Review — Rec 45
Written information about sources of specialist support and legal advice should be passed to every family by the Coroner’s Officer at the very first contact. The Police and IPCC should also be subject to a legal obligation to advise the family of this right immediately on advising the family of …
Policing & Security
Accepted
Angiolini Review — Rec 42
All state agencies who are engaged with the family, including police, IPCC, CPS and Coroners and their staff should provide both oral and written information about support services, including INQUEST, to families as early as possible when contact is established following the death. Agencies should not assume that this has …
Policing & Security
Accepted
IOPC Review — Rec 70
The IOPC should ensure all bereaved families are provided with its guide for families on how the IOPC investigates and supports them following a death and the deaths in or following police custody leaflet developed following the Independent Review of Deaths and Serious Incidents in Police Custody. It should routinely …
Policing & Security
Angiolini Review — Rec 41
The Government should ensure that families have funded access to appropriate bereavement services offering specialist counselling to families of the deceased. Those providing the services should understand the impact of a traumatic bereavement involving a protracted, intrusive investigation.
Policing & Security
Accepted
Angiolini Review — Rec 38
NHS Trusts should engage with families throughout their own investigations. There should be formal guidelines setting out the nature and expectations of family engagement.
Policing & Security
Accepted
Angiolini Review — Rec 35
The Coroner and IPCC staff should tell families immediately following the death of their loved one of the right to independent free specialist legal advice, the benefit of securing advice from the earliest possible stage and the right to representation of a pathologist at the post mortem or to request …
Policing & Security
Accepted
Angiolini Review — Rec 34
Written information about sources of specialist support, including information about INQUEST, should be given to every family at the very first contact with an IPCC representative, as well as alternative forms of information taking into account the needs of the individual next of kin.
Policing & Security
Accepted
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
Domestic Homicide Reviews(15)
Monmouthshire — recommendation 11
When family members, friends or other personally interested parties appear at the scene of a homicide, a Duty Supervisor is always appointed to support them, act as an information conduit and explain crime scene procedure. They also ensure that other close relatives are promptly informed either by themselves or by …
Gwent Police
Gwent Police
Newham — recommendation 4
That ELFT examine its processes for information sharing with carers and families and effectively involve them in risk assessment. This should include provision of carers’ packs and clear written guidelines for carers on the availability of a crisis line. Consideration should also be given to the potential risks to the …
East London Foundation Trust
East London NHS Foundation …
Blackburn With Darwen — recommendation 1
The Community Nursing Service review procedures in regard to bereavement visits/family contact to ensure support for families following any death not just those receiving end of life care.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Liverpool — recommendation 23
To ensure that when checking a patient into the accident and emergency department, full identifying details of next-of-kin are always recorded. Where a patient indicates that they do not have a next-of-kin, this should be clearly documented.
Royal Liverpool and Broadgreen University Hospitals …
Royal Liverpool and Broadgreen …
Lambeth — recommendation R11b
LEO CMHT to develop a protocol to state that relatives and patients are to be given a copy of the treatment care plan on the day of the assessment including crisis contact details
SLaM LEO CMHT
Merton — recommendation 2.1
The LEO Operational Policy should be updated to provide guidance to care coordinators working with families and carers. How they can access needs assessment/support from Trust services and/or be signposted to the local authority for a carer’s assessment under the Care Act 2014. This should include guidance on sharing care …
South London and Maudsley NHS Foundation …
South London and Maudsley …
Wandsworth — recommendation DHR3b
FLOs, as our first point of contact with the families of victims, should have specific training about DHRs and how families can help the reviewers see the tragedy through the eyes of the victim, their family and friends and therefore help them to make the best recommendations.
Metropolitan Police Service
Metropolitan Police Service
Exeter — recommendation R4
Review how well Devon Partnership Trust policies and procedures on contact with families fit with the national consensus statement on information sharing and suicide prevention.
Devon Partnership Trust
Devon Partnership NHS Trust
Northumberland — recommendation 8
NTW should review their position relating to post incident contact with family members following homicide with immediate effect to ensure consideration and decisions on a case by case basis. This should have regard for the police support framework provided through Police liaison officers.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Doncaster — recommendation 4
The Community Safety Partnership should review the process of communicating with and interviewing procedure for the family of homicide victims particularly at the time of the death of the individual to provide consistency, support and compassion.
Doncaster Community Safety Partnership
Aylesbury Vale — recommendation Panel National Recom
The Home Office is recommended to review and learn lessons from Police Forces in respect to the service offered by Family Liaison Officers following a major incident when the family of the victim and the perpetrator are the same. This should include consideration being given to the support offered to …
Home Office
Home Office
Leicester — recommendation 2
Leicestershire Partnership NHS Trust to use the opportunity of the transformation programme to instil into training and awareness of all staff the need for adherence to the requirements of the Care Programme Approach to assess the risks involved in managing patients who have been detained for treatment and are being …
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Dudley — recommendation 3
Dudley Safe and Sound to forge links with the Black Country Healthcare NHS Foundation Trust and support the Trust in its endeavour to secure ‘real-time-surveillance’ data on suicide, and also support the Trust to develop a plan to promptly deliver support to family and friends, as appropriate.
Dudley Safe and Sound | Black …
Black Country Healthcare NHS …
Southampton — recommendation 9.6
That Southern Health NHS Foundation Trust ensure a distressed caller receives a follow up call or if not operationally possible a signposting to an appropriate agency at the time and that they secure a separate and confirmed assurance that the distressed caller has support from family or friends.
Southern Health NHS Foundation Trust
Hampshire and Isle of …
Southampton — recommendation 9.5
That Southern Health NHS Foundation Trust review its ‘Carers Strategy’ to ensure that initial Psychiatric assessments are shared and communicated with the wider family where possible while working with and in event of serious events involving their family or the patient/client. This is in line with recent findings in the …
Southern Health NHS Foundation Trust
Hampshire and Isle of …