Feedback not integrated
Failure of service providers to systematically collect and integrate feedback from staff, service users, and relatives to inform improvements.
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
36 inquiry recs
29 PFD reports
318 committee recs
53 CQC actions
5 HMICFRS recs
14 ICIBI recs
31 PPO recs
32 NAO recs
104 IMB recs
1 detention investigation rec
16 PHSO decisions
179 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(36)
R47 — Quarterly family feedback via external agency
Recommendation: The provider should actively seek family or carer feedback on the service user’s experience on a quarterly basis via an external agency and report the findings to the public part of a Board-level committee minutes (where these exist) and publish …
Response Pending
R46 — Lived experience feedback via external agency
Recommendation: Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and behaviours on a quarterly basis through an external and independent agency (perhaps to be undertaken by the PCC), …
Response Pending
R39 — Guidance on recording and presenting concerns
Recommendation: People with learning disabilities and autistic people and their families should be provided with a short description of how best to record and present concerns so as to be effective.
Response Pending
R38 — Clear pathways for raising concerns
Recommendation: People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for raising concerns. This information should clearly distinguish between an enquiry, a concern and a complaint. Individuals should then …
Response Pending
R20 — Independent advocacy for service users and families
Recommendation: Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising concerns and complaints. DoH/SPPG should specify the level of advocacy services required for people with learning disabilities in …
Response Pending
BRIS-28 — Routinely seek, act on, and publish patient feedback and experience surveys across NHS
Recommendation: Patients must be given the opportunity to pass on views on the service which they have received: all parts of the NHS should routinely seek and act on feedback from patients as to their views of the service. In addition, …
Unknown
RHI-35 — Early Warning Systems
Recommendation: Better systems are needed for spotting early warnings and concerns from the public and businesses that something unexpected could be happening or going wrong with an initiative. Simply updating existing complaints and whistle-blowing policies, although helpful, will not be sufficient, …
Gov response: [Note: The NI Executive responded to recommendations 8-18, 24, 26-28, 32b, 34-36 together as a group under the 'Professional Skills, Resourcing, Record Keeping and Raising Concerns' themes.] NI Executive Response (October 2021): These recommendations can …
Accepted
R78 — Audit committee implementation tracking
Recommendation: HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully …
Response Pending
AC-2d — Structured Response to Community Input
Recommendation: To build confidence that IBCA is actively listening to people infected and affected, IBCA adopt more of a structured response to contributions from people infected and affected. Consideration should be given, as a minimum, to making a contemporaneous record of …
Gov response: The remaining 11 recommendations focus on IBCA delivery. Further detail on these will be set out by IBCA in due course.
Accepted
F198 — Measuring cultural health
Recommendation: Healthcare providers should be encouraged by incentives to develop and deploy reliable and transparent measures of the cultural health of front-line nursing workplaces and teams, which build on the experience and feedback of nursing staff using a robust methodology, such …
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
F113 — Complaints handling
Recommendation: The recommendations and standards suggested in the Patients Association's peer review into complaints at the Mid Staffordshire NHS Foundation Trust should be reviewed and implemented in the NHS.
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
F12 — Fundamental standards of behaviour
Recommendation: Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff are entitled to receive feedback in relation to any report …
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
IBI-A-2e — Transparency of Scheme Design
Recommendation: The Government and IBCA establish a mechanism by which individuals or organisations may raise concerns which arise about any aspect of the scheme which from time to time is troubling them. The mechanism is intended to help continuous improvement of, …
Gov response: The Inquiry was clear that there is a need for greater transparency, involvement and listening with the community in remedying injustice by the state. The Government accepts that, together with IBCA, it makes available a …
Accepted
MAI-112 — Give consideration to NHS commissioner recommendations
Recommendation: The Department of Health and Social Care should give urgent and close consideration to any recommendations made by the trusts and the NHS commissioners.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
IBI-10a(v) — Yellow Card System Prominence
Recommendation: Steps be taken to give greater prominence to the online Yellow Card system to those receiving drugs or biological products, or who are being transfused with blood components.
Gov response: The online Yellow Card system is UK wide and therefore this recommendation has been addressed on a UK wide basis. The Yellow Card system has provided vital feedback, but we agree with the inquiry that …
Accepted
LADB-89 — HSC to review compliance with recommendations and publish review outcomes.
Recommendation: A review of compliance with the above recommendations should be conducted on behalf of the HSC within six months of publication of this report, and further reviews should be put in hand as necessary thereafter. The HSC should publish the …
Unknown
LADB-17 — Develop a blame-free culture for safety information communication in industry
Recommendation: The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Unknown
BRIS-166 — PCTs must involve public in commissioning hospital services and gather feedback
Recommendation: Primary care trusts (and groups), given their capacity to influence the quality of care in hospitals, must involve patients and the public, for example through each PCG/T’s Patient and Advocacy Liaison Service. They must make efforts systematically to gather views …
Unknown
BRIS-165 — NHS Modernisation Agency to advise on achieving widest public and patient involvement
Recommendation: The involvement of the public, particularly of patients, should not be limited to the representatives of patients’ groups, or to those representing the interests of patients with a particular illness or condition: the NHS Modernisation Agency should advise the NHS …
Unknown
BRIS-164 — Provide financial resources to support public involvement, covering costs like childcare
Recommendation: Financial resources must be made available to enable members of the public to become involved in NHS organisations: this should include provision for payments to cover, for example, the costs of childcare, or loss of earnings.
Unknown
BRIS-163 — Provide training and guidance to properly support public involvement processes
Recommendation: The process of public involvement must be properly supported, through for example, the provision of training and guidance.
Unknown
F159 — Training and training establishments as a source of safety information
Recommendation: Surveys of medical students and trainees should be developed to optimise them as a source of feedback of perceptions of the standards of care provided to patients. The General Medical Council should consult the Care Quality Commission in developing the …
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
F158 — Training and training establishments as a source of safety information
Recommendation: The General Medical Council should amend its standards for undergraduate medical education to include a requirement that providers actively seek feedback from students and tutors on compliance by placement providers with minimum standards of patient safety and quality of care, …
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
F151 — Complaints to MPs
Recommendation: MPs are advised to consider adopting some simple system for identifying trends in the complaints and information they received from constituents. They should also consider whether individual complaints imply concerns of wider significance than the impact on one individual patient.
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 in Part
13 — Improve complaints handling
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in responding to complaints, and introduce measures to promote the use of complaints as a source of improvement and reduce defensive 'closed' responses …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
BAHA-46 — Lessons Learned Process
Recommendation: The MoD should consider whether the lessons learned procedures need to be adjusted or supplemented so that the clearer and more urgent lessons and changes to previous practice are fed back far more quickly both to the operational theatre and …
Gov response: Accepted. Lessons learned processes have been improved for faster dissemination.
Accepted
AC-2c — Community Advisory Body
Recommendation: A formal role be given within IBCA for an advisory body consisting of people infected and affected, covering a range of experience broadly representative of those groups, and (if those groups so wish) including clinicians covering the major relevant disciplines …
Gov response: The remaining 11 recommendations focus on IBCA delivery. Further detail on these will be set out by IBCA in due course.
Accepted
IBI-10a(i) — Patient Satisfaction in Clinical Audits
Recommendation: A clinical audit should as a matter of routine include measures of patient satisfaction or concern, and these should be reported to the board of the body concerned. Success in this will be measured by comparing the measure of satisfaction …
Gov response: UK Government The Health Secretary, the Rt Hon Wes Streeting MP, in setting out his mission for saving the NHS earlier this year, stated his aim to return to the “highest patient satisfaction in history”. …
Accepted
IBI-9b — Trust/Board Action on Peer Reviews
Recommendation: That NHS Trusts and Health Boards should be required to deliberate on peer review findings and give favourable consideration to implementing the changes identified with a view to ensuring comprehensive, safe, care.
Gov response: UK Government Recommendation 9a-9c: Peer review of UK comprehensive care centres has been an essential part of haemophilia services for many years. The triennial audit was replaced in 2019 with a more formal peer review …
Accepted
IBI-7e — Implementing SHOT Reports
Recommendation: Implementing SHOT reports: That all NHS organisations across the UK have a mechanism in place for implementing recommendations of Serious Hazard of Transfusion (SHOT) reports, which should be professionally mandated, and for monitoring such implementation.
Gov response: UK Government Work is underway to develop governance practices for the implementation of SHOT recommendations, with careful consideration given to the needs for standardisations and the needs of local organisations. Accreditation for SHOT as an …
Accepted in Part
HIDD-52 — Provide appropriate feedback to drivers reporting signalling irregularities on outcomes
Recommendation: BR shall ensure that drivers, reporting on signalling irregularities, are given appropriate feedback on the outcome.
Unknown
24 — Involve patients and relatives in incident investigation
Recommendation: We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking …
Gov response: 37. We accept this recommendation. A duty of candour has been introduced. 38. A lack of openness and honesty at Morecambe Bay was a fundamental cause of both the distress of the families, and of …
Accepted
IBI-2b — Treloar's School Memorial
Recommendation: A memorial be established at public expense, dedicated specifically to the children infected at Treloar’s school. The memorial should be such as is agreed with those who were pupils at Treloar’s.
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
IBI-2a — UK and Devolved Memorials
Recommendation: A permanent memorial be established in the UK and consideration be given to memorials in each of Northern Ireland, Wales and Scotland. The nature of the memorial(s), their design and location should be determined by a memorial committee consisting of …
Gov response: The Inquiry’s report emphasised the need for public recognition and a formal apology for all of those impacted. The previous and current UK governments have issued unequivocal apologies for what happened on behalf of the …
Accepted
BRIS-31 — Require trusts to publish periodic reports on patient views and actions
Recommendation: Trusts and primary care trusts must have systems for publishing periodic reports on patients’ views and suggestions, including information about the action taken in the light of them. (See further the Recommendations on care of an appropriate standard.)
Unknown
HIA-2 — Memorial at Stormont
Recommendation: We recommend that a suitable physical memorial should be erected in Parliament Buildings, or in the grounds of the Stormont Estate.
Gov response: No formal government response published.
Accepted
Prevention of Future Deaths reports(29)
Stanley Dobson
Concerns: Locum doctors failed to report patient non-response to the operative, hindering further contact efforts. Protocols need extending to ensure non-responses are consistently reported.
Response (Department of Health): The Department of Health acknowledges the concerns about staff ratios in care homes, explains that there are no set ratios due to varying resident needs, and refers to existing regulations …
Overdue
Garrett Joseph Franklin Elsey
Concerns: A document on people in commercial waste containers ('Waste 25') may not have been read widely in the waste industry, and an alert system could improve awareness.
Overdue
Gary Richards
Concerns: Psychiatric services failed to properly assess self-harm risk, communicate patient vulnerabilities, ensure follow-up due to unrecorded contact details, and implement crucial recommendations from a previous incident report.
Response (South London Maudsley NHS Trust): The Trust has secured funding for a mental health specific homeless project, linked to an existing scheme across hospitals. There is now an expectation that discharge summaries will be sent …
Responded
Scott Hooper
Concerns: Incorrect patient weight recording led to inaccurate anticoagulant dosage, and critical clinical decisions were unrecorded. Lessons from internal meetings were not effectively disseminated or applied to all high-risk patients.
Overdue
Raymond Davidson
Concerns: Persistent operational staff shortages and overwhelming demand are causing severe and unacceptable ambulance response delays. Additionally, telephone contact not directly with the patient compromised the initial clinical review.
Overdue
Venkata Kagga
Concerns: Critical safety features for button batteries in household devices are lacking, and national safety alerts are not effectively sustained. Hospital policies for paediatric assessment and compliance were not followed, exacerbated by poor information sharing across services.
Response (HSIB): HSIB has launched a scoping exercise, including collecting further details about the incident and conducting a short literature review, to examine whether the case meets their criteria for investigation.
Overdue
Edward Lundy
Concerns: Poor continuity of care, inadequate family consultation on discharge risks, and lack of evidence for implementing recommended improvements in mental health risk management for GP trainees were identified.
Overdue
Roger Neaves
Concerns: Confirmation is needed that the recommendations from the Hospital Trust's Root Cause Analysis following the patient's death have been fully implemented.
Overdue
Ffion Jones
Concerns: The improvement plan failed to address specific issues, and there's no dedicated pathway for urgent clinical discussions between external healthcare professionals and ambulance staff to ensure proper assessment of response urgency.
Overdue
Andrew Wing
Concerns: A CT Aorta was not performed despite an abnormal X-ray and suspected aortic dissection, partly because radiologists reviewing images remotely receive insufficient clinical information for accurate diagnosis.
Response (the General Medical Council): The General Medical Council acknowledges the concerns and has forwarded the report to their Employer Liaison Adviser to discuss with the Trust. If the Trust identify any individual clinicians whose …
Response (the Society of Radiographers): The Society of Radiographers acknowledges the coroner's concerns and highlights the importance of referrers providing sufficient clinical information under the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 17). They are …
Overdue
Darren King
Concerns: There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
Overdue
Patricia McAdam
Concerns: The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.
Overdue
Wendy Wilkes
Concerns: The GP practice lacked a clear system for alert notes or follow-up appointments for patients with extensive prescriptions and failed to assess risks associated with high alcohol use mixed with prescribed medication.
Response (Tameside Glossop): Haughton Thornley Medical Centres conducted a Significant Event Analysis and implemented safeguarding changes, including alert notes for prescribed medication and training staff to share information on intentional/accidental overdoses with GPs. …
Response (Greater Manchester Health and Social Care Partnership): The CCG will ensure practices undertake a quarterly search for patients taking opioids or neuropathic drugs cross-referenced with alcohol dependence. Practices will review their systems to alert prescribers to patients …
Responded
Ruben Bousquet
Concerns: Weak reporting and information sharing processes for food allergy fatalities hinder timely investigations and learning. The feasibility of food businesses carrying adrenaline auto-injectors also needs official investigation.
Response (Medicines and Healthcare Products Regulatory Agency): The MHRA sought advice from the UK Commission on Human Medicines (CHM) on a range of areas to support the effective and safe use of AAIs. The AAI EWG recommended …
Response (Food Standards Agency): The FSA is undertaking consumer research to gather information and insights from people with food allergies and is considering the benefits of developing a food allergy safety scheme for allergen …
Response (Dept for Health and Social Care): The FSA is establishing a way for people to directly report information regarding anaphylactic reactions caused by food allergies that do not result in death. The MHRA is considering making …
Responded
John Berrow
Concerns: An optometrist failed to recognize a critical sign of intracranial pressure, lacked proper reference tools, and there was no system for disseminating clinical incident learning.
Response (Specsavers): Specsavers will commission a specialist optometrist or neuro-ophthalmologist to deliver training materials (concentrating on this topic) which will be recorded and disseminated via an online webinar available to all professional …
Responded
Anne Bradley
Concerns: Lack of scope guides during colonoscopies reduced tumour localisation accuracy, and the absence of a formal feedback system prevented endoscopists from learning about tattooing issues or incorrect tumour identification.
Response (British Society of Gastroenterology): The British Society of Gastroenterology does not support a generalised recommendation on the use of MEIs based on this particular case and states the surgeon is ultimately responsible for identifying …
Response (Royal College of Physicians): The Royal College of Physicians, following consultation with JAG, disputes that the lack of a magnetic imaging device was the primary factor in the patient's death, citing multiple contributing factors …
Response (National Institute for Health and Care Excellence): NICE states that it has guidelines covering cancer recognition/referral and colorectal cancer management, but not colonoscopy or specific equipment; they consider that no action is required by NICE.
Response (St Richards Hospital): St Richard's Hospital reports that scope guides are already in place on the site and confirms that a system to ensure information in relation to tattooing is documented, monitored, and …
Overdue
Michael Jaggs
Concerns: An agency nurse provided suboptimal care, but the agency failed to provide additional training or encourage reflective learning, unlike the hospital, raising concerns about safety improvements.
Response (MedPure): The agency has outsourced complaints to a clinical team, implemented a policy for reflective statements upon complaint, and can offer immediate additional training; they have also assisted the nurse in …
Responded
Mohammed Salam
Concerns: The Root Cause Analysis for a medication omission lacked rigor, failing to investigate causal factors or consequences, which raises concerns about organizational governance and learning from deaths.
Response (Northern Care Alliance NHS Foundation Trust): Northern Care Alliance has implemented consultant countersignatures on ward round outcomes, updated grand round and weekend handover proformas to include an ePMA review checkbox, and updated the junior doctors' handbook …
Responded
Mared Foulkes
Concerns: The university's examination results system is complex and misleading, with provisional passes and pending marks causing confusion. There is also no system for personal tutors to proactively contact vulnerable students before releasing failed results.
Response (Cardiff University): The University has reviewed its process for releasing in-year resit results to ensure all available results are ratified at the Main Examining Board in June. The practice of using notional …
Responded
Christine Cumbers
Concerns: The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future reoccurrences.
Response (Ranworth Medical Group): Ranworth Medical Group addressed the consultation concern with the individual clinician and disseminated learning at a practice meeting on 9/8/22 in an anonymous manner. They completed an audit of consultations …
Responded
Thomas Ithell
Concerns: The Health Board failed to raise incident reports or investigate a patient being lost to follow-up, citing time constraints and an un-user-friendly system, undermining patient safety governance.
Response (Betso Cadwaladr University Health Board): Betsi Cadwaladr University Health Board has raised an incident report and initiated a full investigation into a patient lost to follow-up; it also plans to survey staff experiences with the …
Responded
Arlo Lambert
Concerns: The Antepartum Haemorrhage guideline lacked urgency regarding potential sinister causes and occult bleeding. The Trust also failed to capture early reflective staff accounts, impeding effective safety improvements.
Response (Sherwood Forest Hospitals NHS Trust): The Trust updated its Antepartum Haemorrhage guideline to emphasize the importance of immediate assessment of fetal and maternal condition with any degree of bleeding. They have also developed a phone …
Responded
Eden Street
Concerns: Information from parents of autistic children via a helpline is not fed into weekly audit meetings, risking critical updates on deteriorating neurodiverse patients being missed by clinicians.
Response (Humber Teaching NHS Foundation Trust): Humber Teaching NHS Foundation Trust is implementing a new electronic record keeping system with a risk review form for the duty team to capture call information, and is establishing 'safety …
Responded
Brian Kneale
Concerns: Ineffective and inaccurate monitoring of fluid balances hinders clinicians' decision-making and prevents hospital reviews from learning correct lessons.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): The Trust will update its Fluid Balance policy, roll out a new fluid balance chart with colour coding and other improvements, introduce mandatory afternoon checks, and update its Record Keeping …
Responded
Derek Cole
Concerns: The GP practice failed to communicate abnormal test results to specialists or ensure follow-up, and lacked a robust system for learning from significant events, delaying critical internal reviews.
Response (Attleborough Surgery): The practice has had a clinical meeting to discuss responsibility for notification of GP-generated results to the hospital and the SEA protocol has been amended. Training for GPs and all …
Responded
Sarah Cunningham
Concerns: Transport for London (TfL) has not implemented concrete plans to mitigate risks to intoxicated passengers, despite recognizing the issue and encouraging public transport use by impaired individuals.
Response (Transport for London): Transport for London (TfL) will trial new technologies this financial year to identify customers on the track, starting with the Docklands Light Railway, Central line, and Piccadilly line, and continue …
Responded
Etta-Lili Stockwell-Parry
Concerns: The neonatal investigation into the child's death was inadequate, failing to interview key staff and relying on incomplete records. Learning from the investigation was poorly shared and lacked context, hindering genuine organizational change.
Response (Betsi Cadwaladr University Health Board): Betsi Cadwaladr University Health Board has made immediate safety changes including that investigations across women's and neonatal services will have a single investigation officer and use the framework and templates …
Responded
David Heffer
Concerns: The treating doctor was not informed of the patient's readmission for a complication, and medical records were incomplete and illegible, hindering proper care and investigation.
Response (East Suffolk and North Essex NHS Foundation Trust): The Trust has implemented a new escalation procedure which requires the on-call consultant for the week, to be contacted when an emergency patient is readmitted following a procedure. The Trust …
Responded
Samuel Parkin
Concerns: Hospital learning points from a child's death were not formally disseminated, and ultrasound reports gave false reassurance about malrotation due to poor understanding of USS limitations, delaying crucial diagnostic tests.
Response (NHS England): NHS England will issue national guidance around the limitations of ultrasound to diagnose malrotation and the provision of second opinions, highlighting the importance of communication between teams and multi-disciplinary discussion. …
Response (St Georges Epsom and St Helier University Hospitals): St George's has summarised learning from the case and is presenting at governance meetings; met with Epsom & St Helier; leading a malrotation session; and formalised written referrals to paediatric …
Responded
Select committee recommendations(318)— showing 50 strongest matches
#32 —
Recommendation: The introduction of national standards should be accompanied by a single national complaints and incident reporting portal for taxi and private hire services. It should be digitally inclusive, route reports to the responsible authority, and include clear service standards for …
Response Pending
#31 —
Recommendation: Complaints and incident reporting arrangements are fragmented. In some areas they are difficult for passengers and drivers to navigate, reducing transparency and weakening accountability. (Conclusion, Paragraph 112)
Response Pending
#30 —
Recommendation: One of the clear strengths of the Treasury’s response in the initial stages of the crisis has been its willingness to listen and adjust its policies in response to feedback. However, we are disappointed in its refusal to implement recommendations …
Gov response: We remain alert to the needs of people and stand ready to adapt our approach to match the situation. The Treasury is continuing to monitor trends in consumer spending and our economic response will continue …
Under Consideration
#18 —
Recommendation: In terms of things it could have done better, the Department said that, if it were to do the same thing again, it would try to find a way to do more user testing before the scheme started. The Department …
Not Addressed
#7 —
Recommendation: The Committee recommends that the PHSO learns from and implements best practice at the Local Government and Social Care Ombudsman by publishing feedback scores about its service, split between those complainants who were happy with the result of their case …
Gov response: We have recently completed a six-month pilot, which required staff to come into the office a minimum of two days per week pro rata, to develop an evidence base for a longer-term hybrid model of …
Under Consideration
#6 —
Recommendation: The PHSO have improved the data output about their own performance in recent years, which the Committee applauds. Nevertheless, the Committee is of the view that even more open and transparent access to feedback data will enable external stakeholders to …
Gov response: As we start implementing PHSO’s new People Strategy, the focus is to strive for an inclusive colleague community. We have been integrating best practice into our recent recruitment drive. During 2021–22, 27.7% of appointed candidates …
Under Consideration
#14 —
Recommendation: The Government must listen to and engage with survivors of forced adoption practices. The Government should commit to a survivor engagement strategy that guarantees regular consultation and clear lines of accountability, both in the short term as the Government works …
Response Pending
#9 — Publish guidance on providing timely, detailed, and consistent feedback for all funding bids.
Recommendation: We recommend that the DLUHC provides better guidance on how it will provide feedback on bids. The guidance must set out that feedback is timely, detailed, and consistent. This is especially important for levelling up funds as the quality of …
Gov response: The department is reflecting on lessons it has learnt from Levelling Up Fund rounds one and two including on feedback and will apply those lessons in any future approach to feedback.
Not Addressed
#18 — DWP under-utilises customer survey data to understand experiences of diverse claimant groups
Recommendation: Since 2019 DWP has contracted Ipsos to undertake a regular customer experience survey.36 We asked DWP whether it could track customer satisfaction for customers with disabilities or additional needs. DWP said it had done some analysis of its customer experience …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The department captures customers’ additional needs through its systems. This is a key part of its modernisation strategy, but it recognises that its current …
Accepted
#3 — Gather data to understand diverse customer experiences and act to improve support services.
Recommendation: DWP does not understand well enough the experience of vulnerable customers and customers with additional or complex needs. DWP’s customers have a wide range of vulnerabilities and additional or complex needs due to poverty, age, health problems and disabilities. DWP …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The department captures customers’ additional needs through its systems. This is a key part of its modernisation strategy, but it recognises that its current transformation plans …
Accepted
#15 —
Recommendation: These failures are symptomatic of significant cultural problems that cannot be readily explained by issues with the wider regulatory framework: this includes South East Water’s failure to engage with external stakeholders, inclination for groupthink, inability to analyse problems, incapability to …
Response Pending
#13 —
Recommendation: South East Water has failed to engage with key stakeholders outside the company to help it learn from its mistakes. It is unwilling to properly listen to its customers, who have repeatedly complained of addressable failures 42 and yet continue …
Response Pending
#10 —
Recommendation: The Tunbridge Wells incident and Ofwat investigations reveal that South East Water’s leadership has repeatedly proved itself incapable of implementing the lessons learnt from previous incidents, even simple ones such as having a communication strategy for when resolution timeframes are …
Response Pending
#17 —
Recommendation: Communication and engagement with the fishing industry on the outcomes of the annual UK–EU consultations for 2026 regarding changes to technical measures were inadequate, with unclear messaging on implementation timelines and confusion even among delivery bodies. This has left industry …
Response Pending
#19 —
Recommendation: The Department recognised that the instructions for schools were not clear enough at the start of the scheme, and it also attributed this to its lack of user-testing.33 Edenred told us that it had not been able to engage with …
Not Addressed
#16 —
Recommendation: The Department acknowledged that there was a period early in the scheme when parents and schools experienced quite a lot of difficulty and disruption in getting access to the vouchers. It said that it had underestimated the extent to which …
Not Addressed
#9 —
Recommendation: It is clear that further work needs to be done on the way in which the prison service more generally responds to recommendations. It is important for all organisations that they are able to learn from external sources of assurance. …
No Published Response
#39 —
Recommendation: The Government should provide a full response to the Glover Review before the 2021 summer recess.
Gov response: The government recognises the importance of well-managed protected areas for nature recovery, and acknowledges that there is scope to improve the effectiveness of their management. We have committed to protecting 30% of our land and …
Not Addressed
#19 —
Recommendation: Our previous work has shown a mixed picture in terms of the views of end users regarding the satisfaction and success of programmes introduced in response to the pandemic. Gathering feedback from end users and frontline workers is vital for …
Not Addressed
#16 —
Recommendation: The Tenant Farmers Association told us that its members participating in the pilot were finding the scheme guidance confusing, with an onus on farmers to decide what they think is best to enable the delivery of public goods.48 The National …
Gov response: 7: PAC conclusion: We are concerned that ELM will be too complex and bureaucratic and will not cater for the full range of farm types and circumstances. 7: PAC recommendation: The Department should urgently write …
Not Addressed
#5 —
Recommendation: The PHSO should set out how it plans to take to address the three-long term, low performing scores relating to how evidence is gathered, how decisions are reached and how decisions are made in a timely final decision.
Gov response: PHSO commissioned Sir Liam Donaldson and Sir Alex Allan in 2018 to review PHSO’s approach to using specialist clinical advice in casework. To date, PHSO has delivered and fulfilled 22 of the 25 recommendations of …
Under Consideration
#13 —
Recommendation: Survivors of historical forced adoption practices have stressed the profound emotional burden of continually recounting their experiences and the many years they have spent campaigning without feeling heard by Government. It is clear to us that ongoing, structured dialogue with …
Response Pending
#9 —
Recommendation: The Government must work directly with mothers, adult adoptees and lived-experience organisations to co-author both the apology and the measures that follow it. Co-production should run through all subsequent commitments on accessing records, trauma-informed health support, intermediary services, research and …
Response Pending
#8 — DLUHC lacks a consistent, department-wide process for providing competitive bid feedback.
Recommendation: We heard evidence which brought into question the extent of support provided to applicants or unsuccessful applicants by DLUHC. There is a wide gap in perception between the quality of feedback the DLUHC said it had provided and the quality …
Gov response: In both rounds of the Levelling Up Fund, we have provided feedback to all unsuccessful applicants whose bids passed the initial gateway stage. In round one, this took the form of verbal feedback sessions, with …
Accepted
#13 — HMCTS user feedback mechanisms exist, but significant user concerns remain unaddressed.
Recommendation: It explained that it had several ways it can gather user feedback. For example, it told us that every director in HMCTS was sponsoring an area of the programme which allowed them to listen to user feedback first-hand. HMCTS also …
Gov response: 2.1 The government agrees with the Committee’s recommendation Recommendation implemented 2.2 The decision to adjust the timetable for delivering new Common Platform functionality came directly from listening to and responding to feedback. 2.3 The Crime …
Accepted
#4 — Require all departments to collate feedback from whistleblowers at the end of the process.
Recommendation: The Cabinet Office and other departments do not seek feedback from whistleblowers and so are missing vital insights into the effectiveness of the process. The ‘whistleblowing heath check’ guidance from the Cabinet Office suggests departments should gather feedback from individuals …
Gov response: The government agrees with the Committee’s recommendation. Target implementation: end 2024 The Cabinet Office will work with departmental leads to develop ways on how it can better capture whistleblowers' experiences, including whether they have experienced …
Accepted
#17 — Government lacks comprehensive understanding of effective VAWG interventions and mechanisms to share good practice.
Recommendation: Government departments have a limited understanding of what works to tackle violence against women and girls (VAWG). Since 2021–22, the Home Office has spent at least £4.2 million on new research into what works, but the projects funded are not …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The recommendation is being implemented through work undertaken to support the VAWG Strategy and any ongoing analytical work on tackling VAWG. 4.3 The Home …
Accepted
#4 — Require Home Office to capture and share evidence of successful local VAWG initiatives.
Recommendation: The Home Office has a limited awareness of initiatives proving effective so cannot use this information to improve its understanding of what works to prevent and reduce violence against women and girls. The Home Office acknowledges that departments do not …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The recommendation is being implemented through work undertaken to support the VAWG Strategy and any ongoing analytical work on tackling VAWG. The Home Office regularly reviews …
Accepted
#5 — Develop and publish a comprehensive stakeholder engagement framework for marine decision-making by January 2025.
Recommendation: We recommend that the Department for Environment, Food and Rural Affairs (DEFRA) develops a comprehensive framework for engaging a diverse range of stakeholders, particularly coastal communities and underrepresented voices, early-on in marine decision-making and outline the responsible organisation for leading …
Gov response: Stakeholder engagement is highly valued by the Department, its Arms-Length Bodies (ALBs) and Ministers. It is a central part of policy delivery and implementation. In tandem, Defra fully recognises the importance of being clear about …
Partially Accepted
#4 — Strengthen stakeholder engagement across all marine policy areas within Defra.
Recommendation: Engaging stakeholders in a meaningful way is essential to ensure that decisions are inclusive, transparent, and responsive to both environmental and societal needs. For engagement to be effective, it must occur through appropriate forums, begin early in the decision-making process, …
Gov response: Stakeholder engagement is highly valued by the Department, its Arms-Length Bodies (ALBs) and Ministers. It is a central part of policy delivery and implementation. In tandem, Defra fully recognises the importance of being clear about …
Partially Accepted
#8 — Involve stakeholders and parent organisations in SEND reforms; publish annual progress reports.
Recommendation: It is essential that the Department addresses these challenges if it is going to succeed in making mainstream education inclusive and fixing the broken SEND system. The Department must involve stakeholders in reforms and begin to consult with parent-led organisations …
Gov response: Our response at this time is deliberately high-level and further detail on our plans for SEND reform will be set out in the Schools White Paper early in the new year following a further period …
Partially Accepted
#32 — Formalise a two-way learning mechanism between domestic and international energy initiatives by June 2026
Recommendation: The Government should formalise a mechanism for systematic two-way learning between domestic and international energy initiatives and formally identify ways UK businesses could grow their international footprint through community energy investments. It should be in place by June 2026 (Recommendation, …
Gov response: Government Response: Partially Agree 73. The FCDO works closely with DESNZ as well as UK industry to incorporate and share lessons learnt from the UK’s transition story. For example, our Green Cities, Infrastructure and Energy …
Partially Accepted
#26 — AIRE service lacks follow-up mechanisms, creating accountability gap for complaints
Recommendation: Migrant Help is not contracted to follow up on or monitor issues and does not have sight of the response from providers and the Home Office. This creates a significant gap in accountability. We recognise the value of enabling asylum …
Gov response: Delivering the AIRE service solely at a local level would be challenging due to its scale, regulatory requirements, and need for consistent 24/7 support. The current model supports over 106,000 asylum seekers and manages high …
Not Addressed
#23 —
Recommendation: We look forward to the results of the evaluation of two culturally appropriate advocacy pilot schemes, which the Government should expand if the results are positive. (Recommendation, Paragraph 126) Other issues
Gov response: We are pleased that the Committee welcomes the culturally appropriate advocacy pilots which DHSC has funded. These pilots aim to improve provision of advocacy for ethnic minority groups who we know are not well served …
Not Addressed
#16 —
Recommendation: Repeating the same actions and expecting different results is not a well- regarded tactic for resolving problems. Yet the non-executives of South East Water have time and time again chosen to back a leadership that is clearly not capable of …
Response Pending
#14 —
Recommendation: Continued leadership failure is grounds for leadership change. Time and again, since 2020, South East Water’s leadership has failed in its fundamental task of supplying water to its customers. That is around six years of poor performance, sometimes with multiple …
Response Pending
#12 —
Recommendation: South East Water’s leadership team has demonstrated a clear preference for blaming factors outside of their control for performance issues, and in some cases, they continue to do so, despite clear evidence to the contrary. A lack of data-analysis skills …
Response Pending
#11 —
Recommendation: Since at least 2020, South East Water clearly has had, and continues to demonstrate, an inability to establish the root causes of its supply resilience problems. There are likely many facets to this, including a failure to monitor the key …
Response Pending
#9 —
Recommendation: For a company with such regular issues with outages, South East Water’s approach to supporting vulnerable customers gives the impression of a business caught completely by surprise. We accept that it is challenging to continuously update the Priority Services Register: …
Response Pending
#8 —
Recommendation: Similarly to the provision of alternative water supplies, South East Water now has years of experience in communicating during supply interruptions. It is incomprehensible that SEW still lacks a crisis communications strategy or a well-developed communications team given the company’s …
Response Pending
#7 —
Recommendation: Given the huge number of supply interruptions that South East Water has failed to manage over the years, it is remarkable that the company still struggles with the supply of bottled water during outages, has failed to learn and apply …
Response Pending
#6 —
Recommendation: Both the Drinking Water Inspectorate and South East Water acknowledge the weaknesses of the escalation processes around the Pembury incident. This meant that operational staff were not given sufficient support to diagnose problems early and that key stakeholders were informed …
Response Pending
#5 —
Recommendation: Despite South East Water’s assertions to the contrary, periods of peak demand and extreme weather can and should be broadly predicted and prepared for. Ofwat and the Drinking Water Inspectorate have shown that the company failed to model upcoming peaks …
Response Pending
#4 —
Recommendation: As regulators told South East Water repeatedly and jointly for over four years, the company needed to invest in new infrastructure to be properly resilient to potential shocks. In particular, single points of failure, supply shortfalls and regional connectivity should …
Response Pending
#3 —
Recommendation: Maintenance issues at Pembury contributed to the Tunbridge Wells incident in 2025, but it is South East Water’s self-identified lack of proactive and “instinctive” maintenance across its network that is most concerning. One of the most fundamental and basic responsibilities …
Response Pending
#2 —
Recommendation: South East Water did not have the right processes in place to identify and mitigate risks at Pembury Works, despite previous warnings from the DWI. That the company had “normalised” critical risks and was “flying blind” in the lead up …
Response Pending
#18 —
Recommendation: Small bodies are not always aware of the support and resources provided by sponsor departments and the centre of government. The Director of Finance and Operations of the Government Actuary’s Department told us that she is only aware of many …
Response Pending
#17 —
Recommendation: There was a clear divergence of opinion between some disabled people and their organisations, who felt excluded and ignored by the Government, and Ministers, who described their engagement with disabled stakeholders during the pandemic as very positive, open and effective. …
Gov response: We think it this is important too. We do try to find out what disabled people think about government decisions in lots of different ways: ● online workshops ● advisory committees ● listening to research …
Under Consideration
#7 —
Recommendation: It is a startling indictment of senior managers at MTC that the overwhelming majority of recommendations made by the joint inspectorates in February 2020 were not actioned. Those managers and the company appear largely to have ignored those recommendations until …
No Published Response
#7 —
Recommendation: It is imperative staff have the opportunity and the confidence to speak up. However, this needs to be matched with a culture in which organisations demonstrate that they are not just listening to, but also acting on, staff feedback. While …
Gov response: 3.1 We recognise the importance of encouraging a positive culture where people are empowered to speak up and where they feel that their voices will be heard, and ideas acted upon. We will explore with …
Under Consideration
CQC inspection actions(53)— showing 50 strongest matches
The Peter Gidney Neurodisability Centre
We recommend that the provider reviews how it responds to feedback from people and their relatives to make service improvements.
Should Do
The Peter Gidney Neurodisability Centre
There was no learning from accidents and incidents and no steps were taken to ensure incidents did not happen again.
Must Do
Psychiatry-UK LLP
The service should ensure there are mechanisms in place to learn from near misses.
Should Do
Psychiatry-UK LLP
The service must ensure learning from near misses or incidents is consistently communicated to all staff.
Must Do
Charmes Care
The registered persons failed to have effective systems in place to assess, monitor and improve the quality and safety of the service and to to seek and act on feedback from people, relatives, and staff to continually evaluate and improve …
Must Do
Birmingham
The service should ensure the new complaints manager improves the breadth and depth of learning from complaints. Regulation 16.
Should Do
Kingsley Nursing Home
The registered manager and provider failed to: 4. Evaluate and improve care for people where failings had been identified. 17 (2f)
Must Do
Ashbourne House - Torquay
The provider did not have effective systems and processes in place to ensure the ongoing monitoring and quality of the service. People's feedback was not obtained to improve and develop the service. The provider did not act on feedback from …
Must Do
Affinity Trust Specialist Support Division North
The provider had failed to ensure learning was used to inform improvements associated with risk and the provision of people care.
Must Do
Verve Health
The service should ensure collating outcomes of treatment to establish effectiveness.
Should Do
Verve Health
The service should ensure that regular full staff meetings, staff multi-disciplinary meetings and handovers occur in order to discuss service user needs, share relevant key information and share learning or areas for improvement.
Should Do
Verve Health
The service must ensure service user safety incidents are managed, staff report incidents appropriately and managers investigate incidents and share lessons learned with the whole team.
Must Do
Universal Care - Beaconsfield
The provider failed to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services). The provider failed …
Must Do
Charlton House Medical Centre
The practice had completed one full clinical audit, however it had not created a formal plan to audit clinical areas specific to the needs of the practice population identified as at risk during our previous inspection which continued to place …
Must Do
Westacre Nursing Home
We have asked that the registered manager ensure there are more robust systems in place to ensure this does not happen.
Should Do
Sunnyside
Further improvement was required in the level of detail, particularly around what action staff had taken to de-escalate people's behaviour prior to the use of medication. Furthermore, no analysis of incidents had occurred in order to identify any potential trends …
Should Do
St Marks Residential Care Home
We recommend the provider reviews reports from other care providers who have been rated outstanding, to support them in this area.
Should Do
St Marks Residential Care Home
We recommend the provider seek advice and guidance from a reputable source on how they can make their meetings more inclusive.
Should Do
Lady Ida Lodge
Feedback around communication showed improvements were needed, as people were not always informed when their calls were running late or not taking place.
Should Do
Gedling Village Care Home
Further work was needed to embed and sustain these changes.
Should Do
Figtree Care Services Ltd
The results of the survey had not been fed back to people and their relatives and if any improvements were planned because of their feedback. This is an area that needs improvement.
Should Do
Diamond-Garrott Ltd @ Belmont House Clinic
Record and review information from external sources including peers, stakeholder and regulatory bodies.
Should Do
DMC Church View Practice
Continue to analyse incidents and near misses and consider how processes can be improved as a result.
Should Do
Capital Homecare (UK) Limited
The provider seeks guidance from reliable sources on developing an effective framework of investigating and analysing incidents and act to update their practice accordingly.
Should Do
Bousfield Surgery
Take action to acknowledge complaints in accordance with the providers complaint policy and document any learning from complaints.
Should Do
Rosecroft Residential Care Home
The provider should ensure that action plans or records are in place to show how people's feedback from resident meetings and other sources has been consistently addressed.
Should Do
Park Cottages
The registered provider and registered manager did not have an effective oversight of the service. The quality monitoring systems in place did not identify or address the concerns found during this inspection. The registered provider did not have an effective …
Must Do
Haversham House Limited
The provider must ensure effective quality assurance tools are in place to identify where improvements are required at the service and that change is implemented effectively.
Must Do
Grosvenor Hall
Inadequate systems and processes to assess, monitor and improve the service meant that lessons failed to be learnt. The provider had failed to reduce or remove risks where possible which had a negative impact on people using the service.
Must Do
Floron Residential Home for the Elderly
This was a continued breach of regulation 11 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Cygnet Bury Hudson
The provider must ensure that any complaints or concerns raised by patients, their families or carers, are logged, acknowledged, investigated, complainants are informed of the outcome in line with provider policy and lessons learned from investigating complaints are implemented and …
Must Do
Crown Street Surgery
Improve processes to record and share any learnings identified from complaints.
Should Do
Valewood House Nursing Home
We recommend that that manager considers a structured approach to gathering people’s views to ensure that they have regular opportunities to share concernsor ideas.
Should Do
The Homestead (Crowthorne) Limited
The registered manager said they would look to introducing a checklist to record them.
Should Do
Haversham House Limited
Improvements were required in medicines, risk management and oversight within the home that had been identified at a previous inspection. This meant improvements in these areas had not been implemented or effectively embedded into practice and sustained.
Must Do
Westwood Residential Care Home
Governance and oversight was not robust, and quality assurance processes failed to identify concerns found during this inspection.
Must Do
Unit 4 Cornishway Industrial Estate
Ensure incidents that affect the health, safety and welfare of people using services are appropriately recognised and reported. Incidents must be reviewed and thoroughly investigated by competent staff and monitored to make sure that action is taken to remedy the …
Must Do
The Withins
There continued to be a missed opportunity to complete analysis of incidents to establish if patterns or themes were emerging to prevent or minimise reoccurrence of incidents.
Should Do
The Grange Residential Home
The provider did not have robust processes in place to monitor the safety and quality of the service. The provider had failed to seek and act on feedback in order to improve the service.
Must Do
Standon House
Improvements were noted since the last inspection but these needed to be reviewed to ensure they were effective and embedded into the management teams' practice. For example, the infection prevention reviews failed to address and correct staff members practice for …
Should Do
Ranyard at Mulberry House
Systems were not established to seek and act on feedback from relevant persons on the services provided for the purposes of continually evaluating and improving the services.
Must Do
Ranyard at Dowe House
We recommend that the service find ways to consult and gather the feedback of people about the service provided.
Should Do
Percys Travel
The service should consider implementing their own audits to utilise data generated as part of their sub-contract agreement to improve the service.
Should Do
Holmesley Nursing Home
We recommend that good practice advice in respect of setting and achieving improvement plans is reviewed and implemented.
Should Do
Donnington House Care Home
Processes were not in place to ensure management oversight of accidents and incident records. The registered manager told us they did not have oversight of accidents and incidents and were not aware of any processes to identify trends, drive service …
Should Do
Valewood House Nursing Home
The manager should consider a structured approach to gathering people’s views to ensure that they have regular opportunities to share concerns or ideas.
Should Do
Specialist Medical Transport - North
The service must evidence that managers have investigated incidents thoroughly and learned lessons from these incidents or recognised potential safeguarding factors in these incidents.
Must Do
Precious Nursing & Residential Home
The provider must act and investigate complaints.
Must Do
Auckland House
We recommend the provider seeks current guidance and best practice on systems and processes for engaging people and seeking feedback and update their practice accordingly.
Should Do
Ashmore House
The provider must establish and operate effective systems to seek and act on feedback from relevant persons to continually improve the service.
Must Do
HMICFRS recommendations(5)
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond …
Recommendation
Efficiency spotlight report: The impact of recruitment and retention on the criminal …
Invest more in understanding why staff left and use this information to inform future changes to improve recruitment and retention
Recommendation
The hidden victims: Report on Hestia's super-complaint on the police response to …
Commission work to better understand victim experience of police response to modern slavery
Recommendation
FRS 2023-25 CoC Recommendations: Shropshire Fire and Rescue Service
Cause of concern: The service doesn’t have adequate processes, controls or internal governance arrangements in place to manage strategic risks, performance and improvement plans. Recommendation: The service should develop an action plan to make sure it has access to accurate …
Recommendation
ICIBI immigration recommendations(14)
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should set up an Afghan resettlement schemes working group to engage with stakeholders, the voluntary sector, NGOs and Afghan community groups to provide updates and seek feedback …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 9 Review the assurance regime at Stansted and relaunch it so that it is no longer regarded as a “tick-box exercise” with little value, ensuring that those responsible for …
An inspection of Border Force operations at Stansted Airport
Recommendation 9 Review the assurance regime at Stansted and relaunch it so that it is no longer regarded as a “tick-box exercise” with little value, ensuring that those responsible for …
An inspection of Border Force operations at south coast seaports
Record information about searches and other activities conducted by Border Force at and from each port in a consistent format and in sufficient detail to improve knowledge of the threats …
An inspection of asylum casework (August 2020 – May 2021)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (June - October 2023)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of illegal working enforcement (August – October 2023)
In relation to assurance: (a) as a matter of priority, re-introduce a formal first-line assurance process. (b) ensure that second-line assurance covers all operational areas, including planning activity. (c) review …
Inspection report on family removals, July 2010
Home Office response to the recommendations The Home Office accepts or partially accepts all recommendations.
A re-inspection of Border Force operations at Coventry and Langley postal hubs
The Home Office response to the recommendations:
An inspection of the EU Settlement Scheme
The Home Office response to the recommendations:
An inspection of the EU Settlement Scheme (April 2019 to August 2019)
The Home Office response to the recommendations:
An inspection of the Home Office’s processing of family visas September 2021 …
The Home Office response to the recommendations:
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should: ensure that all existing and future equality impact assessments in relation to Afghan resettlement schemes have a defined review date, with an assurance mechanism in place …
An inspection of Border Force operations at south coast seaports
Look again at Project Kraken, in particular at the reporting arrangements, and identify if it could be made more effective. 6.3. Accepted. 6.4. As advised during the course of the …
PPO death in custody recommendations(31)
The Governor
The Governor should ensure that this report is shared with a CM and a OSG and that a senior manager discusses our findings with them.
The Head of Healthcare
The Head of Healthcare should share this report with healthcare staff named in it and discuss its findings with them.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should provide timely feedback to healthcare staff about the good practice identified in the clinical review and consider how this can continue to be role modelled to staff to ensure ongoing good quality care and patient …
The Director at Parc
The Director should share this report with CM A and Officers A, B and C and arrange for a senior manager to discuss the Ombudsman’s findings with them.
The Head of Healthcare at Parc
The Head of Healthcare at Parc should share this report with Nurses A, B and C and discuss the ombudsman’s findings with them.
Practice Plus Group
undertake a clinical audit examining the effectiveness of learning following any significant incident and governance managers need to assure themselves that this learning has been embedded
The Governor
The Governor should share a copy of this report with Supervising Officer A and ensure that a senior manager discusses the Ombudsman’s findings with him.
The Head of Healthcare
The Head of Healthcare should share this report with the specialist psychological therapist and discuss the Ombudsman’s findings with her.
The Governor
The Governor should ensure that staff regularly check and respond promptly to messages left on the Safer Custody hotline.
The Governor of HMP The Verne
The Governor should share this report with the Director of Adult Social Services for Dorset
The Governor and Head of Healthcare at HMP Manchester
The Governor and Head of Healthcare at HMP Manchester should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should introduce a robust quality assurance process to ensure that prisoner applications are promptly responded to and healthcare staff record any action taken.
The Governor
The Governor should ensure that this report is shared with staff mentioned in the report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should share this report with SO A, Nurse A, CM A, Officer C and CM B and discuss the Ombudsman’s findings with them.
The Governor
The Governor should: • Update the at-risk line message given to callers so that it tells them how often messages are checked, whether they can expect a callback, details of the email service and how to escalate immediate safeguarding concerns, …
The Governor
The Governor must carefully consider the findings of this report and the early learning review to ensure that the concerns identified are being addressed.
The Governor
The Governor should undertake a review of the ACCT quality assurance process to satisfy himself that systemic issues are identified, and suitable remedial actions taken in response.
The Governor of HMP Ranby
The Governor should ensure that ACCT reviews are held whenever an event occurs that could mean a prisoner is at increased risk and improve the quality assurance process that confirms this learning has been embedded.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with a healthcare assistant so that he is aware of the Ombudsman’s comments.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with the staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should share this report with Nurse A and discuss the Ombudsman’s findings with him.
The Director
The Director should share this report with SPCO A, PCO A and PCO B and arrange for a senior manager to discuss the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should share this report with the members of healthcare staff who were involved in Mr Ayers’ care and discuss the Ombudsman’s findings with them.
The Governor of HMP Swansea
The Governor should share a copy of this report with the reception officer and arrange for a senior manager to discuss the Ombudsman’s findings with her.
The Governor of HMP Swansea
The Governor should share a copy of this report with the Duty Governor and discuss the Ombudsman’s findings with him.
The Head of Healthcare of HMP Swansea
The Head of Healthcare should share a copy of this report with the reception nurse and discuss the Ombudsman’s findings with her.
The Governor of HMP Holme House
The Governor should share this report with CM A and Officer A and arrange for a senior manager to discuss the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should undertake an audit of hospital discharge plans to ensure that the agreed plan has been enacted and develop an action plan based on the findings.
The Prison Group Director for Avon and South Dorset
The Prison Group Director for Avon and South Dorset should write to the Ombudsman setting out what is being done to improve ACCT procedures at Bristol.
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should liaise with the hospital to develop a system to improve communication to ensure that changes in appointments are communicated effectively.
NAO audit recommendations(32)
Transforming courts and tribunals: a progress update
• put in place structures to ensure learning about how services are impacting those using them is captured and fed into the development of new services.
Accepted
Progress on the courts and tribunals reform programme
Get a better understanding of how efficiently reformed services are working so it can identify where improvements are needed. HMCTS should consider how to get more routine and timely data on how efficiently reformed services are working, including where variation …
Accepted
The Creation of the UK Infrastructure Bank
The Bank should develop approaches to assessing whether its engagement with local authorities, other stakeholders and the market is working as intended.
Accepted
Progress with trade negotiations
DIT should improve the effectiveness of its engagement with businesses, consumers and the public. It should ensure that the mechanisms it has established for engaging with stakeholders are sufficiently inclusive in giving all parties opportunities to engage, access information and …
Accepted
Improving Single Living Accommodation
The Department should carry out and make use of work on the ‘lived experience’ to better understand what personnel want from SLA and inform future accommodation plans. The Department should look at how it can regularly collect data on experiences …
Accepted
Digital Services at the Border
The Department should: a) build on the recent progress the programme board has made in understanding risks, and its tracking of progress, to set up ways of working in line with the scale and pace of implementation it now requires …
Accepted
Specialist skills in the civil service
All functions should collect data on the impact and benefits of their training initiatives, to ensure training resources are targeted and deployed most effectively.
Accepted
DCMS’s management of its COVID-19 loan book
DCMS should: e Develop its approach to gathering and learning lessons, working with its loan agents and external providers, so that it has a knowledge management plan to ensure relevant background and insight are preserved over the loan book?s lifetime. …
Accepted
DCMS’s management of its COVID-19 loan book
DCMS should: c Working with its loan agents, set out an overarching engagement strategy for borrowers and how it expects to adapt this over time, as the scale and nature of its portfolio changes. Within this it should use its …
Accepted
The Farming and Countryside Programme
f use available feedback channels to explore in more depth farmers? capacity for, and response to, continuing change going forward and how it will affect trust and levels of engagement
Accepted
DWP customer service
To improve its customer service, DWP should take action to improve customer service in light of the results of its customer experience survey and follow-up qualitative research, particularly on the reasons for dissatisfaction.
Accepted
NHS Supply Chain and efficiencies in procurement
By the end of 2024, Supply Chain should improve its understanding of why customers are unsatisfied with its services and develop a targeted action plan to make substantial improvements in satisfaction.
Accepted
Investigation into the East West Rail project (Oxford – Cambridge)
EWR Co should continue to revisit its approach to local engagement to ensure the needs of all stakeholders are met, particularly those whose homes and businesses are affected.
Accepted
Department for Education: sustainability overview
f) share evidence, examples and learning with the sector so that schools can make informed decisions about what sustainability interventions would work best for their circumstances.
Accepted
Update on the rollout of smart meters
e) continue to draw lessons from the smart meter rollout to inform the development of other policies that rely on consumer engagement and behaviour changes, particularly the decarbonisation of home heating.
Accepted
Improving resettlement support for prison leavers to reduce reoffending
By November 2023, MoJ and HMPPS should finalise evaluation plans for HMPPS's initiatives to improve prison leavers? access to employment. Where feasible, they should commit to comparing outcomes with control groups and use data and intelligence on trends in local …
Accepted
Improving resettlement support for prison leavers to reduce reoffending
To evidence the impact of its Commissioned Rehabilitative Services, HMPPS should consider implementing a revised approach to its future set of contracts so that it enables providers to systematically report on outcomes achieved for offenders. Where appropriate, HMPPS should verify …
Accepted
Regulating to achieve environmental outcomes
c) By December 2024, enhance mechanisms for sharing evaluation findings and good practice across the Defra group. As Defra implements its new evaluation strategy, it should clearly set out and enhance its approach to communicating internally how evaluation findings can …
Accepted
Investigation into Child Trust Funds
HMRC is increasing its engagement in CTFs now they are maturing. As it is now more closely monitoring and reporting on CTFs, it should seek to re-evaluate the CTF scheme once an appropriate amount of time has passed since accounts …
Accepted
Investigation into Child Trust Funds
HMRC is increasing its engagement in CTFs now they are maturing. As it is now more closely monitoring and reporting on CTFs, it should seek to review its current efforts to raise awareness of the CTF scheme among young adults …
Accepted
The Restart scheme for long‑term unemployed people
h) improve the information it uses to assess customer service standards for future contracts. DWP needs to be able to assess performance in a timely way so that it can act quickly if necessary. This is likely to require some …
Partially accepted
The Bounce Back Loan Scheme: an update
f) set-out key performance measures for each fraud control, and measure performance against them regularly, adapting the approach where necessary.
Accepted
Improving Single Living Accommodation
The Department should agree and set out what a reasonable standard for SLA would look like, drawing on building condition standards but also the ‘lived experience’ work. Progress in both improving SLA to a reasonable standard and then maintaining it, …
Accepted
Managing the BBC’s pay-bill
As the BBC continues to implement its reforms to pay and working practices, we recommend it should: a) ensure it learns lessons, and acts on feedback, from its pilots of changes to scheduling and working patterns to ensure it can …
Accepted
The Farming and Countryside Programme
e develop a comprehensive and unified package of advice for farmers that will best support them in making the changes needed and help them to progress towards activity that delivers greater environmental benefit;
Accepted
The UK border: Implementing an effective trade border
Once controls have been operating for a sufficient period, Defra should, in conjunction with external stakeholders, review whether the new model for sanitary and phytosanitary (SPS) controls provides an appropriate balance between biosecurity and trade flow and make any appropriate …
Partially accepted
Active Travel in England
In establishing itself as a new executive agency, ATE should: g. work with DfT to review the approach to public engagement on active travel. More is required to ensure that there is a good understanding of why active travel is …
Accepted
Tackling local breaches of air quality
j) review their approach to public engagement on Clean Air Zones to do more to ensure that there is good understanding across the country of the purpose of these zones, how and why charging regimes differ and to ensure that …
Accepted
Tackling local breaches of air quality
h) publish six-monthly updates on the progress of the Programme, including the measures local authorities expect to take, their expected implementation date and expected date of local compliance and consider encouraging local authorities to share an update of their progress …
Partially accepted
Tackling local breaches of air quality
c) improve the accessibility and usability of air quality information for the public
Accepted
Regulation of private renting
g) Review whether current dispute resolution arrangements for private renters are appropriate. It should consider in particular whether the arrangements are accessible for all tenants, provide appropriate redress when things go wrong and give the Department sufficient insight into emerging …
Accepted
Evaluating government spending
i) information on which interventions are continued, changed or stopped as a result of evaluations, to demonstrate the practical impact of good evaluation evidence on decision-making and help inform assessments of whether the evaluation system is working as intended.
Accepted
IMB individual recommendations(104)— showing 50 strongest matches
Garth (2022)
To remedy this, at least in part, it is strongly recommended that policy makers, from the top down, should be more willing to consult with those at the coal face who are actually doing the job and who most clearly know what is required.
Ministry of Justice
Noted
Morton Hall (2023)
Extending the contract for librarian services to provide full five-day per week absence-relief cover, avoiding the need to close the library and rely on the trolley service (paragraph 7.1.5). Please note that we also made this recommendation in our previous report.
Governor / Director
Wayland (2024)
management carry out its own review about why the lack of appreciation of their efforts in these important areas stubbornly exists, in addressing the issue revealed in this survey.
Governor / Director
Fosse Way (2025)
Communications could, in our view, be better with various committees/meetings cancelled or changed at short notice without the IMB being informed. This has resulted in situations where we have arrived at a meeting and it has not taken place.
Governor / Director
Onley (2020)
The speed with which prisoner complaints have to be dealt with often results in responses that have not been carefully considered. Prisoners need to have confidence in this process.
HMPPS
In Progress
North Sea Camp (2021)
Prisoners say that the OMU do not respond in a timely manner or keep appointments and that at times OMU staff could be more courteous (paragraph 7.3.2). This needs addressing and maybe the rollout of offender management in custody (OMiC) will help with this.
Governor / Director
In Progress
Humber (2021)
The Board is disappointed to note that there has been little, if any, practical response to the comments raised in the preceding report.
HMPPS
Gartree (2021)
Will the Governor work with the Board to identify ways to continue to improve engagement between the Board and the SMT? The Board acknowledges that aspects of the working relationship have improved, but there are still occasions when the flow of information relies on us asking questions. We are keen to have key information provided so that we have the …
Governor / Director
Foston Hall (2021)
The IMB is concerned about: the underuse of the discrimination incident reporting form (DIRF) system and prisoner feedback which suggest it is not well understood or trusted
Governor / Director
Exeter (2021)
Undertake to improve communication with and feedback opportunities for prisoners (paragraphs 5.4 and 8.3).
Governor / Director
Durham (2021)
The Board is concerned at the length of time it takes for actions to be enacted in the minutes of prison meetings, e.g. DIAT and use of force (5.3.5).
Governor / Director
Littlehey (2023)
The Board has been pleased to see the re-introduction of prisoner forums during this reporting year and the willingness of the prison to engage with the prisoner population to improve their lived experience. The Board has also heard the frustrations of prisoners who feel that these forums can be talking shops rather than action orientated. The Board would like to …
Governor / Director
Ashfield (2023)
In order to retain prisoner goodwill and compliance, can the Director provide reassurance that the rationale for any permanent changes is discussed with prisoners and their concerns are taken into consideration? Any changes need to be clearly communicated to all prisoners.
Governor / Director
Wayland (2024)
prison management should perhaps review how effective they are in addressing prisoners’ concerns by this means. We repeat that suggestion in 2024.
Governor / Director
London STHF (2024)
We have experienced long delays in receiving responses for some rota reports. We would like timely responses so that we can be assured that our concerns are being addressed. At the time of writing, we are waiting for responses on eight reports for the reporting year.
Home Office
Hull (2024)
How will the prison service put systems in place to resolve these issues? The Board note that these same concerns were raised in our 2021/22 and 2022/23 reports with limited progress continuing to be observed by the Board in this area.
HMPPS
In Progress
Gatwick IRC (2024)
Provide more transparency about healthcare complaints and shorter timeframes for response. Provide adequate information to allow the IMB to assess the nature of the complaints and the effectiveness and efficiency of this complaints process.
NHS / Healthcare Provider
Rejected
Dartmoor (2024)
What assurances can the Board be given that the responses are reviewed regularly and that any major planned actions not undertaken are investigated and actioned? Of particular note here would be the Ageing Population Strategy (now over two years’ late), planned overnight health support at HMP Channings Wood (over a year late) and the IPP Annual Report (due six months …
Other
In Progress
Wandsworth (2025)
There has been no satisfactory answer to any of the questions asked of the Prison Service in our previous annual report. Please could you answer the questions?
HMPPS
Manchester (2020)
Other than the regular monthly board meetings, can the Governor offer alternative channels of communication to the Board, to keep them abreast of the changes planned for HMP Manchester in becoming a category B training establishment?
Governor / Director
Bristol (2020)
When the Governor has been able to attend Board meetings, this has been well received, and useful for Board members, although the levels of communication were ad hoc at times and the Board has felt that its statutory role has been compromised on occasion during such a critical period.
Governor / Director
Noted
Aylesbury (2020)
Deliver a systematic, speedy and data-supported response to the recommendations of the last inspection.
Governor / Director
Implemented
Heathrow Immigration Removal Centre (2021)
The healthcare provider should continue to review how they communicate with detainees, especially in relation to the role of the person the seeing, and the associated benefits – for example, promoting the benefits of seeing a nurse. The Board observes that many detainees do not attend a medical appointment they have booked, as they are unsure about seeing a nurse …
NHS / Healthcare Provider
Bristol (2021)
The Board has welcomed Governor attendance at our Board meetings, and useful communication between meetings including with the Deputy Governor. We hope that we will be invited to meet visitors to the prison and attend appropriate debriefings, which did not happen consistently during this year.
Governor / Director
Heathrow Immigration Removal Centre (2022)
The Board found feedback from the healthcare team to the weekly questions and concerns set out in our Rota Reports very disappointing. We would therefore urge the Healthcare Manager to provide a ‘point person’ to respond in a timely manner to our concerns about detainee care.
NHS / Healthcare Provider
Bristol (2022)
The Board wishes to receive more regular updates on performance indicators and progress reports on various initiatives. Can this be provided more often?
Governor / Director
Wayland (2023)
We now ask, however, for prison management to take note of these findings [complaints system fairness] and seek to ensure that the outcome for prisoners involved in the complaints process is at least improved in regard to the precepts of procedural justice, and also, perhaps, seek to provide opportunity to discuss the felt-fairness of complaint responses with prisoners as part …
Governor / Director
Wayland (2023)
We urge the healthcare contractor to consider how this situation [dissatisfaction with complaint results] can be improved.
Other
Wayland (2023)
We now ask, however, for prison management to take note of these findings and seek to ensure that the outcome for prisoners involved in the complaints process is at least improved in regard to the precepts of procedural justice, and also, perhaps, seek to provide opportunity to discuss the felt-fairness of complaint responses with prisoners as part of key working.
Governor / Director
Portland (2023)
The Prison Council serves a very useful purpose in bridging communication between prisoners and management of the prison but, in practice, many prisoners are not aware of its role or who their representative is. What are your plans to strengthen its effectiveness through better publicity and awareness raising?
Governor / Director
Lancaster Farms (2023)
To improve communication with prisoners in key areas such as the progress towards resolving or responding to complaints, availability of programmes and the reasons for re-categorisation.
Governor / Director
Heathrow immigration removal centre (2023)
The Board found feedback from the healthcare team to the weekly questions and concerns set out in the IMB Rota visit report to be untimely and we encourage this to be improved.
NHS / Healthcare Provider
Haverigg (2023)
the Board has not examined specific evidence to support or refute this feedback, but asks the Governor and senior managers to maintain careful and sustained oversight of this important area to ensure consistency.
Governor / Director
Coldingley (2023)
Complaints from prisoners provide a vital insight into aspects of prison life which are not working well. There is evidence that there are has been a deterioration in quality of response to complaints, with many prisoners stating 'there is no point'. What plans does the Governor have to improve the system and restore trust in the prisoners that they will …
Governor / Director
Ashfield (2023)
Can the Director give an assurance that the implementation of the most recently revised IP scheme will be subject to rigorous, ongoing monitoring to ensure that it is closely aligned with the philosophy and practice of the national incentives scheme and it is applied consistently and that it will be subject to a further review in June 2024?
Governor / Director
Wayland (2024)
increase consultation over food within the prison’s communication strategy with its prisoners, as was suggested by the HMIP 2017 Wayland inspection report.
Governor / Director
Wayland (2024)
perhaps a system of update messages, generated at the standard timeframe of five working days for an internal response, might be considered by management, signed off by the relevant SO or CM so that it might be personalised.
Governor / Director
Wayland (2024)
it should be read by Wayland’s prison management and then to respond appropriately to our, and the report’s, findings.
Governor / Director
Implemented
Wandsworth (2024)
There has been no satisfactory answer to any of the questions asked of the Prison Service in our previous Annual Report (see below). Please could you answer the questions?
HMPPS
Moorland (2024)
Further action to improve prisoners’ confidence in the systems for complaints and DIRFs.
Governor / Director
Askham Grange (2024)
The Board recommends that the Governor raises with the head of healthcare prisoners’ concerns that the complaints process within the department should be evident, transparent and its use not discouraged, given that no complaint/concern was recorded as dealt with in person and informally during the reporting period.
Governor / Director
Wayland (2025)
The Board would like to suggest that Practice Plus seriously consider running a survey of their own amongst prisoners to test for themselves the themes we have bulleted above, and also, as a response to the themes we have identified, to consider providing a clear confirmation of the diagnosis made and treatment to be provided after a consultation so the …
NHS / Healthcare Provider
North East Midlands, Yorkshire & Humber STHF (2025)
We request that Care & Custody provide the IMB with a clear timeline and process for consulting with the IMB on the content and outcome of the review.
Other
Bristol (2025)
Please can you ensure that the IMB will consistently receive regular information reports and updates to support our monitoring duties?
Governor / Director
Accepted
Lancaster Farms (2022)
To improve communication with prisoners in key areas such as the progress towards resolving or responding to complaints, availability of programmes and the reasons for recategorisation.
Governor / Director
Preston (2020)
The key worker scheme has been implemented, and the targeted contacts made. This was anticipated to have led to a reduction in the number of applications to the Board, but application numbers have not subsequently decreased. This needs to be investigated further.
Governor / Director
Gartree (2020)
Will the Governor continue to identify ways to improve engagement between the Board and SMT, to enable positive interaction for the benefit of all? This includes routine notifications which are outlined in the memorandum of understanding between HMPPS and the management board for the Independent Monitoring Boards, dated December 2019.
Governor / Director
Dartmoor (2020)
The Board understands that it is now planned to bring facilitators to every wing under the Dialogue Road Mapping (DRM) scheme. However, the nature of DRM means that not much is heard about it, except by word of mouth. Can ways be found of raising its profile in the prison?
Governor / Director
Styal (2021)
The effectiveness of the induction centre has yet to be monitored and reviewed by the Board and it would be helpful to consider its impact, once it is no longer incorporated in the RCU provision.
Governor / Director
Maidstone (2021)
Restart residential governor wing surgeries as soon as possible.
Governor / Director
PHSO casework decisions(16)
P-004292 — Medway NHS Foundation Trust
Mrs F complains the Trust did not implement promised service improvements identified after she complained about the care it provided to her mum, Mrs G.
NHS in England
Nov 2025
P-004652 — Wye Valley NHS Trust
Ms M complains the Trust did not make improvements as promised following a complaint she made about the care it provided to her mother.
NHS in England
Jan 2026
P-001698 — The Royal Wolverhampton NHS Trust
Mrs O complains the Trust did not manage her mother's iron deficiency anaemia properly. She also complains it did not put into place recommendations it published in a report.
NHS in England
Partly Upheld
Jan 2023
P-002847 — Birmingham and Solihull Integrated Care Board
Miss N complains Birmingham and Solihull Integrated Care Board (ICB) has not made the service improvements it said it would make in response to her previous complaint about the continuing healthcare process (CHC) for her father.
NHS in England
Upheld
Aug 2024
P-004406 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mrs A complains about the care and treatment provided to her husband, Mr A, by York and Scarborough Teaching Hospitals NHS Foundation Trust in May 2024. She complains in the four days following his ERCP surgery, the surgical team did not listen to his and his families concerns regarding his …
NHS in England
Dec 2025
P-003058 — Care Quality Commission
Mr and Mrs B complain the Care Quality Commission failed to properly inspect the Nursing Home. The also say It failed to act on intelligence it received about the Nursing Home before the inspection and it did not take account of relevant evidence during the inspection. They also complain about …
UK Government
Partly Upheld
Oct 2024
P-002807 — North Cumbria Integrated Care NHS Foundation Trust
Miss L complains about aspects of her maternity care and treatment, and a lack of action taken when she raised concerns.
NHS in England
Jul 2024
P-003482 — University Hospitals of Leicester NHS Trust
Mrs O complains the Trust has not provided evidence of the implemented change of procedure and learning it outlined in its complaint response.
NHS in England
Apr 2025
P-004392 — A practice in the Mansfield area
Mr R complains the Surgery were dismissive of his health concerns, provided him with inadequate advice, and did not resolve his complaint before closing it.
NHS in England
Dec 2025
P-003162 — Tameside and Glossop Integrated Care NHS Foundation Trust
Mrs N complains Tameside and Glossop Integrated Care NHS Foundation Trust have not taken enough action following a coroner’s prevention of future deaths report.
NHS in England
Nov 2024
P-003189 — An independent provider in the City of Bristol …
Mrs W complains about the care and treatment the Trust provided to her father in January 2023. Mrs W complains about the actions of a paramedic, that the Trust failed to complete actions recommended by an external review and about contradictory information in its complaint response.
NHS in England
Dec 2024
P-003768 — Portsmouth Hospitals University NHS Trust
Miss C complains the Trust did not administer her with antibiotics before her baby was born in September 2024. She also says the Trust did not listen to her concerns about jaundice before and shortly after her and her baby were discharged.
NHS in England
Aug 2025
P-004713 — University Hospitals Birmingham NHS Foundation Trust
Miss A complains about the following aspects of the care and treatment her son, O, received from the Trust when they attended A&E in May 2024. She complains the Trust did not apply the glue and steri-strips correctly to her son's wound, and the Trust did not provide her with …
NHS in England
Upheld
Jan 2026
P-002533 — A practice in the Lincolnshire area
Miss R complains the Practice ignored her requests for pain relief, ignored the request to refer her for an MRI scan, did not examine her during a consultation and failed to treat her urine infection in good time.
NHS in England
Apr 2024
P-002566 — Guy's and St Thomas' NHS Foundation Trust
Mrs C complains about a consultant's decision to discharge her from orthopaedic care in March 2022. She says her concerns were not listened to and red flags were missed.
NHS in England
Apr 2024
P-001442 — Driver & Vehicle Licensing Agency
Mr O complains that the Driver & Vehicle Licensing Agency will not update his log book to reflect that he has modified his vehicle to become a campervan, or tell him what he needs to do for his van to meet its requirements.
UK Government
Partly Upheld
Jun 2022
LGO / SPSO decisions(179)
NIPSO-improving-healthcare-through-better-patient-engagement — Various
Shared decision making in a healthcare setting is about involving patients and their families in decisions about their clinical care. Not only does this foster a more compassionate, effective healthcare service, it is vital for patient safety. By listening to and working with patients, a service is more likely to …
NIPSO (NI Public Service…
Health & Social Care
Sep 2024
21-005-157 — Luton Borough Council
Summary: Mr X complained about the Council’s decision to place parking restrictions outside his property in April 2020 after he raised concerns about vehicles using his driveway to turn around in the road. The Council was at fault when it misunderstood Mr X’s concerns and then failed to communicate with …
LGO (Local Government & …
Transport And Highways
Upheld
Feb 2022
20-010-677 — Wiltshire Council
Summary: The Ombudsman found fault by the Council on Mr Y’s complaint about its failure to investigate his reports of his neighbours’ antisocial behaviour. It failed to show evidence of its antisocial behaviour officer’s involvement, whether it considered if any of their behaviour might be actionable, and whether it considered …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
20-006-249 — Worthing Borough Council
Summary: We will not investigate this complaint about the Council’s response to anti-social behaviour. This is because we are satisfied with the action the Council intends to take. It has agreed to carry out further investigation and consider how the issues impact Mr X.
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
21-005-739 — Bolton Metropolitan Borough Council
Summary: Bolton Metropolitan Borough Council was at fault in relation to Ms B’s complaints about the provision of handwriting support and that its handling of part of Ms B’s complaint to the Council was avoidably delayed. It will apologise to Ms B.
LGO (Local Government & …
Education
Upheld
Mar 2022
21-010-445 — Bristol City Council
Summary: Mr X complained about how the Council dealt with parking issues near his home. We found that, while the Council properly processed changes to local parking restrictions, it failed to communicate clearly with Mr X. The Council’s apologies to Mr X had already addressed the frustration caused by its …
LGO (Local Government & …
Transport And Highways
Upheld
Apr 2022
21-001-922 — Dudley Metropolitan Borough Council
Summary: Mrs X complained the Council did not properly deal with or acknowledge her reports of anti-social behaviour by a neighbour. She said the Council’s actions caused avoidable distress to her and her family. We found fault by the Council and the Council has agreed to provide a remedy to …
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2022
21-014-095 — Wakefield City Council
Summary: Ms F complains about repeated problems with her assisted waste collection service. There was fault which has caused Ms F frustration and difficulties. The Council has agreed to make a payment to her and take actions to improve its service.
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2022
21-009-235 — Calderdale Metropolitan Borough Council
Summary: Ms X complained about a lack of action by the Council in response to her complaints of anti-social behaviour. While the Council did not follow the correct procedures, it did take action but has not gathered sufficient evidence to enable it to take action against any perpetrators. There is …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2022
22-004-381 — Devon County Council
Summary: The Council was at fault because it did not review Ms Y’s occupational therapy assessment. This meant another council completed adaptations to the front of her property which were unsuitable and therefore unusable. This caused avoidable frustration, distress, inconvenience and time and trouble complaining. The Council will apologise, make …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-000-253 — East Riding of Yorkshire Council
Summary: Miss B complained about excessive delay by the Council in completing the statutory complaints process and its failure to implement the agreed recommendations. We found fault in the Council’s failure to implement the recommendations in full and its poor communication with Miss B in respect of these actions. The …
LGO (Local Government & …
Children S Care Services
Upheld
Oct 2022
22-002-681 — Oxfordshire County Council
Summary: Mr R complains about the delay by the Council’s Monitoring Officer in responding to his complaint about its procedure for introducing a low traffic neighbourhood. The Ombudsman has ended our investigation. We uphold Mr R’s complaint. But the Council has taken action which has resolved the issue. No further …
LGO (Local Government & …
Transport And Highways
Upheld
Nov 2022
22-000-598 — London Borough of Havering
Summary: Ms J complained the Council caused delays in deciding her housing register application and failed to respond to her complaint as set out in its policy. She also said its housing service officers customer service was poor. We found the Council’s customer service was poor, and there were delays …
LGO (Local Government & …
Housing
Upheld
Dec 2022
23-020-604 — Cornwall Council
Summary: Mrs X complained the Council failed to properly assess her property and provide her with a wheelie bin in accordance with its eligibility criteria. The Council is at fault because it failed to fully assess Mrs X’s property for the storage and collection of a wheelie bin in line …
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2024
24-011-866 — Ribble Valley Borough Council
Summary: Mr B complained the Council failed to act on noise nuisance and breaches of licensing conditions and failed to identify the venue did not have planning permission until 2024. There was some drift in the Council’s decision-making in 2024 and a lack of liaison with the planning department. That …
LGO (Local Government & …
Planning
Upheld
Jul 2025
24-014-751 — Melton Borough Council
Summary: There was no fault in the Council’s decisions or actions around preventing Mrs X’s garden flooding. However, the Council was at fault for not updating Mrs X as it said it would. We are satisfied the Council has remedied the injustice caused by this.
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
25-003-417 — Coventry City Council
Summary: Mrs X complained the Council continually failed to collect her green waste bin. We find the Council at fault for missed collections and not monitoring the collections as it said it would, causing avoidable inconvenience and frustration to Mrs X. We recommend the Council apologises and reviews its collection …
LGO (Local Government & …
Environment And Regulation
Upheld
Nov 2025
NIPSO-16741 — Belfast Health and Social Care Trust
Our investigation into a complaint about the care and treatment of a cancer patient has led to an apology to the complainant and a review of the issue of pain management on two wards in the Mater and Royal Victoria hospitals.
NIPSO (NI Public Service…
Health & Social Care
Jan 2021
PSOW-202401785 — Vale of Glamorgan Council
Ms A complained about the Council’s management of her complaint. She said that her Stage 2 complaint to the Council was not dealt with by an appropriate person as the Officer concerned had been directly involved with the subject of the complaint. Ms A also raised other issues with the …
PSOW (Public Services Om…
Local Government
Aug 2024
20-013-910 — Royal Borough of Kensington & Chelsea
Summary: Miss X complained about the Council’s handling of her reports of problem noise, particularly its planning enforcement investigations. We found the Council at fault for not keeping in touch with Miss X about its enforcement investigations and it agreed to apologise for the distress this caused Miss X.
LGO (Local Government & …
Planning
Upheld
Mar 2022
21-007-575 — London Borough of Croydon
Summary: Mr X complained the Council sent Enforcement Agents to his home to recover charges for an unpaid Penalty Charge Notice from 2019 against a car he did not own, without any notice. Mr X said the Council ignored his letters and complaint about the matter. There was fault in …
LGO (Local Government & …
Transport And Highways
Upheld
Mar 2022
21-003-359 — Transport for London
Summary: Mr C said Transport for London was at fault for a failure to inform him testing of taxis had resumed after a pause caused by COVID-19. Transport for London was at fault. It said it would contact Mr C when the pause ended. It did not do so. Nor …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
21-016-584 — West Sussex County Council
Summary: We will not investigate this complaint about how the Council dealt with concerns raised about a bus stop located outside the complainants property. This is because there is no evidence of fault in how the Council dealt with the matter.
LGO (Local Government & …
Transport And Highways
Mar 2022
21-007-780 — Havant Borough Council
Summary: Mr X complained the Council repeatedly failed to collect the household waste and recycling where he lives and failed to ensure an improvement in the service. Mr X said this caused him frustration and inconvenience. We found the Council is at fault. We recommended it apologise to Mr X, …
LGO (Local Government & …
Environment And Regulation
Upheld
Apr 2022
21-010-542 — Derbyshire County Council
Summary: Mr X complained about the Council’s decision to approve a cycling and walking scheme which he says was based on a flawed consultation.
LGO (Local Government & …
Transport And Highways
Upheld
May 2022
21-016-319 — North East Derbyshire District Council
Summary: Mrs X complained the Council failed to notify her when plans changed for a development adjacent to her property. We found the Council failed to follow its Statement for Community Involvement by not notifying Mrs X. This was fault. However, we decided on balance, the outcome was unlikely to …
LGO (Local Government & …
Planning
Upheld
Sep 2022
22-004-721 — North Tyneside Metropolitan Borough Council
Summary: Mrs X complained about the Council’s decision to approve a dropped kerb application that did not comply with its policy and about an officer visit. We found the Council was at fault in departing from its policy. The Council’s offer to reinstate part of the dropped kerb, and the …
LGO (Local Government & …
Transport And Highways
Upheld
Nov 2022
22-008-122 — Milton Keynes Council
Summary: Ms X complained about the Council’s delayed response to her reports of a breach of planning control at a neighbouring property and poor communication. The Council was at fault for delay in investigating all aspects of the reported breach and poor communication on planning breach closures. The Council will …
LGO (Local Government & …
Planning
Upheld
Dec 2022
22-003-971 — Huntingdonshire District Council
Summary: Mr C complains the Council failed to properly consider a planning application for an extension at a neighbouring property which he says will harm his residential amenity. We have found evidence of fault by the Council but consider the agreed actions of an apology, payment and review of guidance …
LGO (Local Government & …
Planning
Upheld
Dec 2022
22-002-007 — Lancashire County Council
Summary: Mr X complained the Council failed to give him notice of a road closure. He also says the Council failed to properly deal with his complaint. We find the Council was at fault for how it handled Mr X’s complaint. The Council has agreed to our recommendation to address …
LGO (Local Government & …
Transport And Highways
Upheld
Dec 2022
22-007-695 — Lancashire County Council
Summary: Mr X complained about delays in the way the Council administered a school admissions appeal hearing and that the Independent Appeal Panel failed to properly consider the appeal for a place for his child. The Council was at fault as it delayed arranging the appeal and delayed sending a …
LGO (Local Government & …
Education
Upheld
Dec 2022
24-003-869 — Basildon Borough Council
Summary: We will not investigate this complaint about the Council’s failure to collect a bulky waste collection. We are satisfied with the Council’s proposed actions to resolve the complaint. Further investigation is unlikely to lead to a different outcome.
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2024
23-015-740 — Dorset Council
Summary: Mr X complained the Council did not follow its scheme of delegation when determining a planning application. We have found fault with the Council for failing to consult the relevant ward member. This caused Mr X frustration, but we do not consider that the outcome of the application would …
LGO (Local Government & …
Planning
Upheld
Aug 2024
24-019-309 — St Albans City Council
Summary: Mr B complained that the Council had not followed its own policy when it banned him from trading at one of its markets. We found the Council did not follow its policy on giving warnings, but this did not cause Mr B injustice as he had been allowed to …
LGO (Local Government & …
Other Categories
Upheld
Sep 2025
25-001-285 — Fylde Borough Council
Summary: We have upheld Ms X’s complaint about poor communications by the Council in relation to works carried out under a disabled facilities grant. The Council has agreed to take appropriate action to remedy the uncertainty caused and to address Ms X’s outstanding concerns about the quality of the work …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2025
23-013-852 — North Warwickshire Borough Council
Summary: We have found no fault with the Council for the delays in implementing noise mitigation measures in line with a previous Ombudsman decision. The cause of the delay was unforeseen and unavoidable.
LGO (Local Government & …
Planning
Not Upheld
Oct 2024
24-000-440 — North Warwickshire Borough Council
Summary: We have found no fault with the Council for the delays in implementing noise mitigation measures in line with a previous Ombudsman decision. The cause of the delay was unforeseen and unavoidable.
LGO (Local Government & …
Planning
Not Upheld
Oct 2024
24-003-408 — Stockport Metropolitan Borough Council
Summary: We found fault on Miss P’s complaint about the appeal panel failing to properly consider her appeal against the admission authority’s decision to refuse her daughter Q a place at her preferred school. This caused the family a great deal of distress. The panel failed to properly consider her …
LGO (Local Government & …
Education
Upheld
Nov 2024
201104889 — Business Stream Ltd
Mr C purchased a farm and then discovered there were water leaks on his property. He asked Business Stream for assistance but they did not respond to his request. One year later he discovered that Business Stream should have referred him to their solutions team who track and fix water …
SPSO (Scottish Public Se…
Water
Partly Upheld
Nov 2012
201201234 — Dumfries and Galloway Council
Mr C lives close to a holiday chalet park. The park was first granted planning consent in 1985 but various amendments were later granted. In July 2010 the operator submitted an application to the council for retrospective planning consent. This was granted in March 2011, subject to four conditions. In …
SPSO (Scottish Public Se…
Local Government
Upheld
Apr 2013
201205198 — West Lothian Council
Mrs C planned to open a food takeaway and sought pre-application advice from the council about this. The council gave advice, which was generally positive about the plan, but made clear that it was given without prejudice to the assessment of a formal planning application. When Mrs C submitted her …
SPSO (Scottish Public Se…
Local Government
Not Upheld
May 2013
201301999 — Business Stream
Mr C complained on behalf of a religious establishment that their charity status did not transfer with them when they moved premises. Mr C said that they were unaware of water charges because they had not been billed for eight years, and when they complained, they were told that it …
SPSO (Scottish Public Se…
Water
Feb 2014
201705961 — West College Scotland
Miss C complained about the college's handling of her complaints about being abused on a college-created social media page by another student, and about plagiarism of her work by other students. Miss C also raised concerns about the way the college handled her complaint about their complaints handling. In relation …
SPSO (Scottish Public Se…
Education
Upheld
Aug 2018
24-002-620 — Rother District Council
Summary: Mr X complained about a Council parking notice. We found fault with the notice issued. The Council agreed to provide a suitable apology and waive the notice and amend the wording on future notices and associated documents and signage. The Council also agreed to complete a review of its …
LGO (Local Government & …
Transport And Highways
Upheld
Dec 2025
202008887 — Aberdeenshire Council
C complained to the council about the way in which they had handled their reports about anti-social behaviour by C's neighbours. C also complained about how the council had managed the situation once C had been offered a housing transfer to remove them from the situation. The council investigated and …
SPSO (Scottish Public Se…
Local Government
Not Upheld
May 2023
202201211 — University of Edinburgh
C complained about how the university handled their complaint that related to their disability and housing. We found that the university's decision to request further information from C about their disability to be reasonable and in line with their policy. We also considered it reasonable that the university asked C …
SPSO (Scottish Public Se…
Education
Upheld
Jun 2023
202101546 — A Medical Practice in the Greater Glasgow and …
C is a former patient of the medical practice. C complained to the practice that they failed to address their enquiries about their healthcare, which they submitted to the practice in writing and by email. The practice decided that they could not meet C’s expectations and concluded that there was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2023
202210928 — Glasgow City Health and Social Care Partnership
C complained about the way that the partnership handled their complaint about the care and treatment provided to C’s late sibling. C said that the complaint process had been long and difficult to follow and it had been hard to obtain a clear and final complaint response from the partnership. …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Nov 2024
202308058 — Fife NHS Board
C complained that the board failed to reasonably respond to their complaint about the way a form was completed by the GP at their GP Practice. We found that while the board provided regular updates, apologised for the delay and reasonably managed C’s contact, the length of time responding to …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2024
202302813 — Grampian NHS Board
C complained about the process followed by the board in commissioning and completing a Level 1 Significant Adverse Event Review (SAER) with respect to the care provided to their partner (A), after they had been diagnosed with Barrett’s oesophagus (a condition where some of the cells in the oesophagus grow …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2025