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 21 independent accountability sources, so the source mix matters as much as the headline total.
42 inquiry recs
29 PFD reports
350 committee recs
12 HSSIB recs
213 CQC actions
5 HMICFRS recs
14 ICIBI recs
31 PPO recs
32 NAO recs
104 IMB recs
1 detention investigation rec
162 DHR recs
16 PHSO decisions
179 LGO/SPSO decisions
10 CJINI reports
1 CQC enforcement action
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(42)
5 — Feedback from corrected defects
Recommendation: Railway Group Standards relating to the maintenance and inspection of safety critical systems should require Railway Group members to assess the value of obtaining performance feedback through recording and analysis of corrected defects, and if necessary introduce appropriate measures as …
Unknown
48 — Governors acting on external report comments
Recommendation: Governors should ensure that any relevant comments or recommendations in external reports about their establishments which have implications for the safety of prisoners be brought to the attention of the workforce.
Unknown
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 …
No response yet
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), …
No response yet
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.
No response yet
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 …
No response yet
17 — Simpler fault reporting procedures
Recommendation: Fault reporting procedures should be reviewed and made as simple and convenient to use as practically possible. They should include provision for an acknowledgement and an explanation if relevant (para 16.11).
Unknown
AFA-1 — Patient focus and complaints
Recommendation: The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication …
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
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 …
No response yet
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: These recommendations can be accepted in full. They have been partially addressed through: • the revision of the NICS Code of Ethics; • the GIAFIS review of whistleblowing; • the Leadership Development training for senior …
Accepted
72 — Consultation on Group Standards
Recommendation: Consultation procedures and times involved in revision of Group Standards or the introduction of new Group Standards, should be reviewed by the Inquiry to be held into safety procedures (para 16.8).
Unknown
39 — Database of leaks, spills and ignitions
Recommendation: The regulatory body should be responsible for maintaining a database with regard to hydrocarbon leaks, spills and ignitions in the industry and for the benefit of the industry. The regulatory body should:- (i) discuss and agree with the industry the …
Unknown
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 …
No response yet
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: Today (Monday 21 July 2025) we have given our response to the Infected Blood Inquiry additional report published on 9 July. We accept all recommendations in the report for IBCA.
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: Accepted. Both teams and organisations should develop ways to measure their cultural health, and act on these measures to improve. Cultural health is a matter for all staff groups; everybody who works in the health …
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: Accepted. At present, standards of complaints handling are judged on the basis of the 2009 regulations and the Health Service Ombudsman’s Principles of Good Complaints Handling. While both of these remain important, a more formal …
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: Accepted. The Government agreed in its response to the Inquiry, Patients First and Foremost, that clear accountability for Trust Boards is essential so that they understand their responsibilities to patients. This includes a regard to …
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: Accepted in full
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: Accepted. The General Medical Council has made it clear that it views surveys of medical students and doctors in training as vital in assessing the quality of education and an important tool in evaluating the …
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: Accepted. The General Medical Council has made it clear that it places a high priority on feedback from students and tutors in ensuring both quality education and patient safety, and will look to reinforce this …
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: Accepted in principle. It is not for the Government to advise individual MPs on the systems they employ to identify the wider significance of individual complaints about health and care services. That said, the Department …
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 …
Unknown
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: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
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: Today (Monday 21 July 2025) we have given our response to the Infected Blood Inquiry additional report published on 9 July. We accept all recommendations in the report for IBCA.
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: 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”. Giving patients …
Accepted in part
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: 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 process on …
Accepted in part
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: 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 organisation for …
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. The Inquiry reported on 20 January 2017, the month the Northern Ireland Executive collapsed; the report The Executive Office and the Northern Ireland Office laid before Parliament in September 2019 …
Unknown
Prevention of Future Deaths reports(29)
Stanley Dobson
Concerns: The coroner identified a lack of protocol requiring locum doctors to report difficulties in contacting patients to operatives, which prevented further follow-up action.
Response (Department of Health): • The Department of Health stated that there is no intention to introduce specific staff ratios in care homes, noting that existing regulations require sufficient numbers of suitably qualified staff. … (AI summary)
Responded
Garrett Joseph Franklin Elsey
Concerns: The coroner noted concerns that a key HSE document, "People in Commercial Waste Containers" (Waste 25), may not be widely known within the waste industry, suggesting an alert system to improve awareness.
Overdue
Gary Richards
Concerns: Psychiatric staff did not properly assess the patient's risk of self-harm or communicate vulnerabilities, and there were failures in follow-up due to unreliable communication. Previous recommendations regarding risk assessment and follow-up had not been completed eighteen months later.
Response (South London Maudsley NHS Trust): • Staff were reminded to ensure risk assessments are documented in the correct location on the electronic patient record system. • The Trust secured funding to pilot a mental health … (AI summary)
Responded
Scott Hooper
Concerns: The coroner noted an incorrect weight recording, impacting anti-coagulant dosage, and a lack of clear documentation for clinical decisions. Further concerns were raised about the insufficient dissemination of lessons learned and the absence of a plan for weight estimation training.
Overdue
Raymond Davidson
Concerns: The coroner noted ongoing operational shortages and insufficient ambulance resources within NEAS led to significant delays in urgent case responses. Concerns were also raised about indirect patient contact potentially impacting the initial clinical review.
Overdue
Venkata Kagga
Concerns: The coroner noted insufficient safety features for button batteries in household devices and a lack of understanding of their risks. Concerns were also raised about non-compliance with policies for young children in emergency services, inadequate medical assessments, and poor information sharing across NHS services.
Response (HSIB): • HSIB reviewed the content of the Regulation 28 letter. • HSIB sought advice from a subject matter expert and NHS Improvement. • HSIB launched a scoping exercise to determine … (AI summary)
Overdue
Edward Lundy
Concerns: The coroner identified a lack of continuity in care and inadequate independent family consultation regarding risks upon discharge. Additionally, there was insufficient clarity in the referral for psychiatric review and no evidence that the Trust's recommended actions were implemented or shared nationally.
Overdue
Roger Neaves
Concerns: The coroner sought confirmation that the Hospital Trust had fulfilled recommendations from its Root Cause Analysis following Mr Neaves's death.
Overdue
Ffion Jones
Concerns: The improvement plan presented did not address specific service shortcomings, and there is no dedicated channel for external healthcare professionals to urgently discuss patient clinical needs with ambulance staff to inform response urgency.
Overdue
Andrew Wing
Concerns: A chest X-ray was reported as normal without the radiographer being aware of the differential diagnosis of aortic dissection. The coroner noted that more detailed clinical information provided to radiographers would assist reviews.
Response (the General Medical Council): • The General Medical Council forwarded the report to its Employer Liaison Adviser. • The Employer Liaison Adviser will discuss the matter with the Trust. (AI summary)
Response (the Society of Radiographers): • The Society of Radiographers is preparing new guidance in collaboration with the Royal College of Radiologists and the Institute of Physics and Engineering in Medicine. • This guidance is … (AI summary)
Overdue
Darren King
Concerns: The coroner identified gaps in effective follow-up for high-risk patients with learning disabilities who disengage, and a lack of clear escalation processes. A missing structured medication review in care plans also limited staff awareness of compliance and referral routes.
Overdue
Patricia McAdam
Concerns: The coroner identified a lack of a robust system to ensure regular assessment of patients who decline contact or care from healthcare providers but continue to receive repeat prescriptions.
Overdue
Wendy Wilkes
Concerns: The GP practice lacked a clear system for alert notes and follow-up reviews for patients on extensive prescribed medication. Additionally, there was no system to ensure prescribers were aware of high alcohol use to assess medication interaction risks.
Response (Tameside Glossop): • The GP practice implemented an alert note and review system for patients with extensive prescriptions and alcohol dependency, which includes flagging records, conducting medication reviews, and contacting patients. • … (AI summary)
Response (Greater Manchester Health and Social Care Partnership): • Practices will undertake quarterly searches for patients coded as taking opioids or neuropathic drugs cross-referenced with alcohol dependency, flag their records, review medication, and discuss alcohol consumption. • Practices … (AI summary)
Responded
Ruben Bousquet
Concerns: The coroner noted insufficient reporting and sharing of information on food-related fatalities, identifying the lack of a national register and timely notification to the FSA. Concerns were also raised about the lack of official investigation into the feasibility of food businesses carrying adrenaline auto-injectors.
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare products Regulatory Agency (MHRA) sought advice from the UK Commission on Human Medicines (CHM) regarding the effective and safe use of Adrenaline Auto-injector devices (AAIs). … (AI summary)
Response (Food Standards Agency): • The Food Standards Agency (FSA) has initiated a project to collect data on non-fatal food-based allergic reactions and commissioned work to monitor trends in severe reactions, including establishing a … (AI summary)
Response (Dept for Health and Social Care): • The Department of Health and Social Care is working to support the Food Standards Agency (FSA) in increasing information prevalence regarding food allergy fatalities. • Officials from the Department … (AI summary)
Responded
John Berrow
Concerns: The coroner noted the absence of practical clinical reference tools at Specsavers, leading a practitioner to rely on Google for decision-making. There was also no formal mechanism for sharing clinical incident learning among practitioners.
Response (Specsavers): • The company stated that staff have access to up-to-date online clinical resources via provided computers and can consult senior colleagues or a professional services team. • The company is … (AI summary)
Responded
Anne Bradley
Concerns: The coroner notes that equipment for accurate tumour localisation during routine colonoscopies is not required. Furthermore, St Richards Hospital lacks a formal surgeon-to-endoscopist feedback system for tumour localisation or tattooing issues.
Response (British Society of Gastroenterology): • The British Society of Gastroenterology stated that magnetic endoscopic imaging devices (MEIs) do not provide precise tumour localisation and are not universally recommended by published evidence-based guidelines for this … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians (RCP) stated that placing singular credence on the lack of a magnetic imaging device as the sole rectifiable contributor to the death would be … (AI summary)
Response (National Institute for Health and Care Excellence): • NICE stated that guidance on specific equipment, techniques, and training for colonoscopy is outside the remit of its clinical guidelines. • NICE indicated that professional societies would be more … (AI summary)
Response (St Richards Hospital): • Scope guides are in place on the St. Richard's site, with a move to using them across all sites. • The Trust has instigated a system to ensure tattooing … (AI summary)
Overdue
Michael Jaggs
Concerns: The coroner noted the agency nurse's sub-optimal care and raised concerns that the agency had not provided additional training or requested a reflective statement for the nurse following the incident.
Response (MedPure): • MedPure outsourced its complaints handling to a third-party clinical complaints team. • MedPure implemented a policy to obtain reflective statements at the point of complaint receipt. • MedPure assisted … (AI summary)
Responded
Mohammed Salam
Concerns: The coroner noted that a Root Cause Analysis investigating a missed medication dose was not sufficiently rigorous, as it failed to examine the factors leading to the omission or its consequences. This raised questions about organisational governance standards and learning from deaths.
Response (Northern Care Alliance NHS Foundation Trust): • The Trust implemented a process requiring attending consultants to countersign ward round outcomes to verify the accuracy of reviews and management plans. • Grand round and weekend handover proformas … (AI summary)
Responded
Mared Foulkes
Concerns: The coroner raised concerns regarding the complex and potentially misleading system for sharing examination results, including the delayed ratification of provisional passes. There was also a lack of a system for personal tutors to contact vulnerable students prior to the release of failed examination results.
Response (Cardiff University): • The university reviewed the process for in-year resit results to ensure all available results are ratified at the Main Examining Board in June, removing provisional results. • The practice … (AI summary)
Responded
Christine Cumbers
Concerns: The Practice did not implement learnings identified in its Significant Event Analysis, despite noting shortcomings in their practice. As of the inquest date, no plans or timescales for implementation were available.
Response (Ranworth Medical Group): • The practice addressed the identified consultation concern with the individual clinician through refresher training and reflection. • Learning from the consultation concern was disseminated anonymously at a practice meeting … (AI summary)
Responded
Thomas Ithell
Concerns: The coroner noted a lack of Datix reporting and investigation into how a patient was lost to follow-up. Concerns were raised regarding staff time restraints and the Datix system's usability hindering internal governance processes.
Response (Betso Cadwaladr University Health Board): • An incident report was raised, a rapid review completed, and a full investigation is underway, with a report due by May 2024. • A revised training programme for the … (AI summary)
Responded
Arlo Lambert
Concerns: The Trust's Antepartum Haemorrhage guideline did not convey urgency regarding potential sinister causes of bleeding, and there was no clear system to capture early reflective accounts from staff following significant events.
Response (Sherwood Forest Hospitals NHS Trust): • The Trust updated its Antepartum Haemorrhage guideline to emphasise urgency, immediate assessment, and the expectation of a worse-case scenario, and shared these updates with staff. • A system for … (AI summary)
Responded
Eden Street
Concerns: Information from parents of autistic children, provided via a Trust helpline, is not consistently fed back to weekly audit meetings, potentially hindering the identification of deteriorating conditions and timely adjustments to clinical priorities.
Response (Humber Teaching NHS Foundation Trust): • The Trust has senior clinicians operating a duty system to assess calls and determine next steps for children on the waiting list. • Contacts indicating an increase in risk … (AI summary)
Responded
Brian Kneale
Concerns: Fluid balances were not effectively monitored, leading to clinicians making decisions without important information and hindering internal hospital reviews from learning correct lessons.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): • Online fluid balance training has been made mandatory on a 3-year basis. • An updated fluid balance chart and an escalation process have been designed, tested, and are ready … (AI summary)
Responded
Derek Cole
Concerns: The coroner noted that the GP practice failed to conduct a significant event review or implement agreed learning regarding the communication of abnormal test results to secondary services. This indicates an insufficient system for learning from events, which could impact future patient outcomes.
Response (Attleborough Surgery): • The practice developed and introduced a new protocol and circulated a new policy for communicating abnormal test results to hospitals. • The Significant Event Analysis (SEA) protocol was amended … (AI summary)
Responded
Sarah Cunningham
Concerns: London Underground's corporate thinking does not sufficiently prioritise the risk of intoxication to individual passengers, despite knowing that some will be intoxicated. Learning from a previous investigation appeared aspirational without a concrete plan.
Response (Transport for London): • Transport for London (TfL) has doubled the size of its night team of Transport Support and Enforcement officers to patrol the night tube and check for vulnerable customers. • … (AI summary)
Responded
Etta-Lili Stockwell-Parry
Concerns: The coroner noted concerns that an investigation into care was not thorough, lacking statements from directly involved doctors and relying on incomplete records. There was also insufficient contextual sharing of investigation findings with staff.
Response (Betsi Cadwaladr University Health Board): • The Health Board implemented a new Integrated Concerns Policy in September 2024, providing a single approach to incident, complaint, and mortality reviews and investigations. • A new training programme … (AI summary)
Responded
David Heffer
Concerns: The treating doctor was not informed of Mr Heffer's readmission with a complication, nor was their advice sought. Additionally, medical records were incomplete and illegible, causing interpretation difficulties.
Response (East Suffolk and North Essex NHS Foundation Trust): • Reminders will be provided to general surgical teams to inform procedural endoscopists of ERCP complications, and this will be included in departmental handover guidance and clinical education sessions. • … (AI summary)
Responded
Samuel Parkin
Concerns: Concerns involve formally disseminating learning across St George's and the NHS about malrotation diagnosis, especially ultrasound limitations and upper GI contrast study thresholds. The report also highlights a need for enhanced safety netting advice for abdominal conditions.
Response (NHS England): • NHS England Specialised Commissioning stated it would update the national service specification for Paediatric Gastroenterology, Hepatology and Nutrition. • The updated service specification will reference guidance on second opinions … (AI summary)
Response (St Georges Epsom and St Helier University Hospitals): • The Trust is formally disseminating learning points from the case through departmental meetings, presentations at partner sites, and national conferences. • Understanding of ultrasound limitations for malrotation is being … (AI summary)
Responded
Select committee recommendations(350)— showing 50 strongest matches
#66 —
Recommendation: The OfS should establish an annual mechanism for the sector to provide feedback to the regulator, as is established practice within other regulators. This should involve a survey and an annual meeting with providers driven by the sector’s priorities, in …
Response attribution not verified
#50 —
Recommendation: The OfS should set out annually how it has gathered student input and how this has driven its priorities and decision-making, either as part of its Annual Report or in a standalone report.
Response attribution not verified
#48 —
Recommendation: It was deeply concerning to hear allegations that the OfS issued veiled threats regarding the future of the Student Panel because members raised issues deemed to be of importance to students. This is precisely the sort of activity that the …
Response attribution not verified
#46 —
Recommendation: The OfS’ mechanisms for engaging students, such as the student board member, Student Panel and the National Student Survey (NSS), are welcome and can provide valuable input. However, it is not clear how this input is used by the OfS …
Response attribution not verified
#200 —
Recommendation: Those who deliver policy through the planning system should be consulted on the content and drafting of relevant advice. Defra and DLUHC should work with Natural England and the Environment Agency to develop a suitable consultation method which can be …
Response attribution not verified
#123 —
Recommendation: The Government should introduce targets for stakeholder satisfaction for its arm’s-length bodies as part of the proposed new planning performance framework. Feedback from developers and infrastructure promoters should be regularly sought and acted on.
Response attribution not verified
#118 —
Recommendation: As part of an announcement on planning fees in July 2023, the Government said that it was developing proposals for a new planning performance framework, which will include considering the use of qualitative metrics such as customer feedback. It is …
Response attribution not verified
#38 —
Recommendation: The Government and statutory bodies must meaningfully consult local planning authorities on new advice and policy which will have an impact on their decision making as competent authorities. This process must allow sufficient time for expertise in handling new policy …
Response attribution not verified
#33 —
Recommendation: The Government should introduce targets for stakeholder satisfaction for its arm’s-length bodies as part of the proposed new planning performance framework. Feedback from developers and infrastructure promoters should be regularly sought and acted on.
Response attribution not verified
#28 —
Recommendation: The Government should pave the way in innovating how organisations collaborate and drive change. It should ensure that the delivery expertise and market understanding in Homes England and the Planning Inspectorate is accessible to all departments making policy that will …
Response attribution not verified
#7 —
Recommendation: There is an irreconcilable gulf between the views of clinicians and service users, and that of the leadership and governance bodies in the homecare sector on how well it is performing. While this is a complicated system with multiple variables, …
Response attribution not verified
#194 —
Recommendation: The Probation Service, however, is not making the most out of these partnerships. Referrals do not always contain sufficient information, risk assessments are not always produced and shared in a timely manner, and commissioned partners find it difficult to feed …
Response attribution not verified
#125 —
Recommendation: These pilots should be properly monitored and evaluated to determine whether any of them should be made more widely available. A plan for evaluation is essential to the launch of any new pilots. Best practices should be shared and scaled …
Response attribution not verified
#111 —
Recommendation: We heard that âthere is a plethora of pilot schemes all over the placeâ, some of which are designed to create such incentives. 209 Dr Abramovaite explained that, sometimes, police forces âdo not know themselves what they are runningâ because …
Response attribution not verified
#63 —
Recommendation: Against this âgenerally positive pictureâ, we heard that sentencers âwould like more information on the outcomes of the people they sentenceâ. 104 As Chris Jennings explained, âin usual circumstances the only time sentencers note progress of an order is usually …
Response attribution not verified
#3 —
Recommendation: There is a clear disconnect between what the government hopes is happening, what the companies contracted to deliver the services believe is happening, and what frontline interpreters and legal professionals report is happening with interpreting services in the courts.
Response attribution not verified
#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 status not verified
#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 status not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#63 —
Recommendation: It is concerning that providers do not know who to contact at the OfS with concerns and struggle to receive a timely or helpful response when they do. Providers need to be able to contact OfS staff who are responsible …
Response attribution not verified
#52 —
Recommendation: The Student Panel must remain free to raise issues that are of importance to students, including where the views of students diverge from those of the Government.
Response attribution not verified
#49 —
Recommendation: Given the OfS’ responsibility for defending student interests, it should refresh its approach to student engagement by opening up more of its work to co-creation with students. It should also consider deepening its engagement with student representative bodies, such as …
Response attribution not verified
#47 —
Recommendation: It is positive that the OfS is now considering how the Student Panel can be made more effective and impact more on the OfS’ decision-making. However, it is important that these reforms allow the Panel to continue to focus on …
Response attribution not verified
#10 —
Recommendation: According to the evidence we received, there is perceived to be a lack of intellectual diversity in many central banks, including the Bank of England. Witnesses suggested that this contributed to insufficient challenge on the MPC in 2020 and 2021 …
Response attribution not verified
#192 —
Recommendation: Firms have told us that uncertainty around the FCA’s expectations on the Consumer Duty, including over which markets and customers it applies to is causing them to take an overly risk-averse approach to complying with the Duty, adding unnecessary volume …
Response attribution not verified
#24 —
Recommendation: The Bank emphasised that “the one-team approach was absolutely key [ … ] with Accenture and technology, but also [ … ] the [RTGS] operators”. It saw co-locating business and technology specialists with Accenture staff as vital to break down …
Response attribution not verified
#8 —
Recommendation: It is important that the Bank implements the recommendations in the C&AG’s Report to maximise potential benefits from the new RTGS. However, wider government has an opportunity to learn from the Bank’s successful implementation of this programme, and we therefore …
Response attribution not verified
#6 —
Recommendation: We welcome the amendments the Government has made to the drafting of the Draft Remedial Order in response to our recommendations. (Conclusion, Paragraph 99)
Response attribution not verified
#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 attribution not verified
#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 attribution not verified
#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 attribution not verified
#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 attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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. …
Response status not verified
#39 —
Recommendation: The Government should provide a full response to the Glover Review before the 2021 summer recess.
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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.
Response attribution not verified
#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 attribution not verified
#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 attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
HSSIB safety recommendations(12)
Residual drugs in intravenous cannulae and extension lines
Healthcare trusts acted upon the epic3 guidelines to minimise the number of ports on cannulae several years ago. The change management process at the time did not consider a wide range of stakeholders, including the end users.
Learning Prompt
Outpatient appointments intended but not booked after inpatient stays
HSIB recommends that NHSX’s What Good Looks Like programme includes a requirement for organisations to be responsive to HSIB reports and recommendations within the ‘Safe Practice’ section of its guidance.
Safety Recommendation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS England and NHS Improvement reviews the recommendations arising from the National Review of Asthma Deaths to prioritise and ensure the implementation of recommendations that are outstanding.
Safety Recommendation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
Integrated care boards and organisations that provide mental health care can improve safety by involving people with lived experience and family carers in coaching for executive leaders. This could include creating learning networks within provider collaboratives. By embedding these roles, …
Safety Observation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have processes for effectively feeding back concerns and incidents to secondary care when discharge communications do not meet your needs?
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
Healthcare providers are required to reduce the instances and risk of hospital acquired infections. The introduction of non-ported cannulae was not effectively communicated to end users and this affected the introduction of these items.
Learning Prompt
Outpatient appointments intended but not booked after inpatient stays
HSIB recommends that NHS England and NHS Improvement develops standards and an operating framework that describes the assurance required for all outpatient appointment booking processes, including after an inpatient stay. The assurance should include feedback mechanisms which provide safeguards that …
Safety Recommendation
The use of an appropriate flush fluid with arterial lines
It may be beneficial to recognise that safety risks are not reliably reported and therefore that the likelihood and level of harm may not be accurately reflected through existing reporting systems.
Safety Observation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation know that its correspondence meets the needs of those receiving and acting on the information?
Learning Prompt
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.
Safety Observation
Medication not given: discharge from an acute hospital to the community
How does your organisation support patients to understand how to raise concerns about self-administration of insulin?
Learning Prompt
Support for staff following patient safety incidents
It would be beneficial if the impact of programmes to support staff following patient safety incidents were subject to formal evaluation. This would assist understanding of what is good practice in terms of support delivered and resource required.
Safety Observation
NCEPOD recommendations(3)
CQC inspection actions(213)— showing 50 strongest matches
William Harvey Hospital
The trust should ensure it seeks and acts quickly on feedback from staff for the purposes of continually evaluating and improving services.
Should Do
William Harvey Hospital
The trust must ensure medical staff complete exception reports to identify trends and themes and use these to improve services for patients and staff.
Must Do
Westmorland General Hospital
The service should ensure that recommendations from external incident investigations are fully considered and appropriate, robust action plans put in place.
Should Do
The York Hospital
The trust should ensure that staff receive feedback from incidents.
Should Do
The York Hospital
The trust must ensure that complaints are responded to in a timely way, result in further investigation if indicated and where possible involve family in the investigation.
Must Do
The York Hospital
The trust must ensure that structured case reviews are focussed on the implementation of recommended actions and the actions are monitored, completed, and recorded.
Must Do
The York Hospital
The trust must seek and act on feedback from relevant persons on the services provided, for the purposes of continually evaluating and improving such services.
Must Do
The Princess Royal Hospital
The service should ensure all patients are able to discuss any concerns with staff.
Should Do
The County Hospital
The service should consider improving the response when requesting patient feedback.
Should Do
St Austell Hospital - Penrice Birthing Unit
The service should consider improving how information is displayed on how to give feedback and make a complaint about the service.
Should Do
Scarborough Hospital
The trust should ensure that staff receive feedback from incidents.
Should Do
Scarborough Hospital
The trust must gain assurance that learning from incidents and risks are shared within the organisation to prevent the risk of reoccurrence.
Must Do
Scarborough Hospital
The trust must seek and act on feedback from relevant persons on the services provided, for the purposes of continually evaluating and improving such services.
Must Do
Salford Royal Hospital
The trust must take actions to improve the timeliness of patient complaint responses to within the timescales specified in the trust complaints policy.
Must Do
Royal Victoria Infirmary
The service should ensure that there are effective communications systems and processes to seek and action feedback from staff on the services provided in the provision of the regulated activities. This includes visibility of the senior leadership teams.
Should Do
Royal Victoria Infirmary
The service should ensure that there are effective communications systems and processes to seek and action feedback from staff on the services provided in the provision of the regulated activities. This includes visibility of the senior leadership teams.
Should Do
Royal Victoria Infirmary
The trust must ensure that feedback from staff is used to drive improvements to the quality and safety of services, and once improvements are identified they are made without delay.
Must Do
Royal Sussex County Hospital
The trust must ensure communication structures for staff are clear, easy to follow, and that there are feedback mechanisms implemented for staff who raise individual concerns.
Must Do
Royal Hallamshire Hospital
The trust should ensure that information is widely displayed so that patients know how to complain.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust should consider how Information is analysed and reviewed and its significance is understood. For example, how results should be escalated, and appropriate action taken.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust should ensure it seeks and acts quickly on feedback from staff for the purposes of continually evaluating and improving services.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure medical staff complete exception reports to identify trends and themes and use these to improve services for patients and staff.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must operate an effective complaints procedure which includes providing timely responses and updates to complainants.
Must Do
Pilgrim Hospital
The trust should consider monitoring staff’s compliance with the systems in place to enable learning from incidents.
Should Do
Northwick Park Hospital
The trust should ensure all staff receive feedback from incidents.
Should Do
Northwick Park Hospital
The trust should ensure all staff consistently receive feedback from incidents across the medicines division.
Should Do
North Devon District Hospital
The service should aim to ensure recommendations made from Ockenden 2020 and 2022 are considered and changes made are made so within a timely manner.
Should Do
Mount Vernon Cancer Centre
The trust should ensure relevant staff are aware of audit outcomes and their ward/area’s end of life care performance.
Should Do
Mount Vernon Cancer Centre
The trust should ensure learning from incidents and mortality and morbidity reviews is consistently shared from board to ward.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldcontinuetoensurethatcomplaintsarerespondedtoinlinewithtimescalessetoutinthetrustpolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensureitcontinuestooperateeffectivesystemstorespondtocomplaintsandtakeappropriateactionwithoutdelaytoanyfailuresidentifiedbyacomplaintortheinvestigationofacomplaint.
Should Do
Kidderminster Hospital and Treatment Centre
Develop processes to ensure that cross division feedback and learning can be shared following the reporting of incidents in the outpatient department, which are investigated by different divisions.
Should Do
Great Western Hospital
The service must ensure non-compliant audits are acted upon and improvement plans put in place.
Must Do
Fleetwood Hospital
The trust should ensure it continues to improve its complaints processes so that responses are compassionate, fully investigated in a timely way and reflective of the findings.
Should Do
Ellesmere Port Hospital
The trust must ensure staff feedback is captured and responded to appropriately to identify risks and drive improvement in services.
Must Do
Doncaster Royal Infirmary
The trust should ensure staff report incidents following their occurrence.
Should Do
Doncaster Royal Infirmary
The trust should continue to ensure that complaints are responded to in line with timescales set out in the trust policy.
Should Do
Doncaster Royal Infirmary
The trust should consider ways to improve the provision of ward meetings to share learning from incidents.
Should Do
Doncaster Royal Infirmary
The trust should ensure it continues to operate effective systems to respond to complaints and take appropriate action without delay to any failures identified by a complaint or the investigation of a complaint.
Should Do
Castle Hill Hospital
The service should seek to further collate and review patient and family feedback to improve services.
Should Do
Barnet General Hospital
The trust should make sure they initiate changes to services based on feedback received from women and implement the changes with the support of the MVP.
Should Do
St Benedict's Hospice
The service should seek to further collate and review patient and family feedback to improve services.
Should Do
Royal Papworth Hospital NHS Foundation Trust
The service should review the way it collects patient feedback to reflect the views of patients using the diagnostic imaging department.
Should Do
Fairfield General Hospital
The trust should ensure that information to provide feedback, including how to complain, is clearly displayed in all areas.
Should Do
Withington Community Hospital
Provide patient feedback at a local level.
Should Do
Tower Hamlets Out of Hours GP Service
Review systems to ensure that all clinical staff are aware of learning from incidents.
Should Do
Stamford & Rutland Hospital
The trust must ensure they seek and act on feedback from both staff and patients to improve the service.
Must Do
Salisbury District Hospital
The team should work to evidence action taken when staff raise concerns.
Should Do
Royal Sussex County Hospital
The trust should continue to carry out the actions they identified from the national audits such as the Lung Cancer Audit 2017 and National Audit of Inpatient Falls 2017.
Should Do
Poole Hospital
Consider how to improve the feedback to staff who report incidents and how feedback from staff on other matters can be shown to be gathered and acted upon.
Should 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
Health investigations(204)
Independent investigation: Katie Kazmi, Reading (1999) — Rec 8
The Home Office response to supervisors’ reports should reflect the reports’ contents rather than merely acknowledging their receipt.
south_east
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Tribunal members should be informed about the clinical outcomes for patients following discharge decisions, and confidential retrospective reviews should be held in cases where patients re-offend seriously after discharge.
east_of_england
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.18.7
The response of a Trust or other agencies to the findings and recommendations of an independent investigation should be monitored, and if recommendations are not implemented within a reasonable time the agencies concerned should be required to account for this failure to an external, independent body.
south_west
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 9
To review Trust procedures to ensure the dissemination of information to senior clinical staff of the conclusions and recommendations of internal and external reports investigating serious untoward events.
north_east_yorkshire
Independent investigation: Trevor Spencer, Dagenham — Rec R4
The trust should ensure that there are systems in place to enable staff involved in a seriousuntoward incident to receive feedback from the subsequent investigation.
london
Independent investigation: Simon Widger, Eastbourne, Sussex (2000) — Rec 9
There is outstanding work from the Internal Review and the panel considers that the organisations involved in the internal review should complete the implementation of the following: (numbering corresponds to numbering within Internal Review Report dated December 2000.) a) 9.2. It is imperative that all Information Sharing Protocols include the …
south_east
Independent investigation: Robert Newby, Sticklepath (2007) — Rec 13
The Trust need to review the SUI Policy to include: the introduction of reflective feedback sessions following serious incidents and near misses; the involvement of clinical teams in the development of recommendations; how learning and recommendations are to be shared across the Trust; greater clarity about the involvement of the …
south_west
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 14
The Trust need to review the Serious Untoward Incident (SUI) Policy to include: The introduction of reflective feedback sessions following serious incidents and near misses. The involvement of clinical teams in the development of recommendations. How learning and recommendations are to be shared across the Trust. Greater clarity about the …
south_west
Independent investigation: Pauline StephenHanane Parry, Aintree Merseyside (2003) — Rec 8
The Primary Care Trust should emphasise to General Practitioners the importance of providing feedback should any concerns be perceived on the clinical status of service users who are known to be in contact with mental health care services.
north_west
Independent investigation: Paul Royston Herbert, Brent (2010) — Rec Ten
It is recommended that Camden and Islington NHS Foundation Trust are sent a copy of this report as the responsible organisation for the Inreach mental health service at Pentonville Prison.
london
Independent investigation: Odessa Carey, Washington (2019) — Rec 14
CNTW and Northumberland CCG should ensure that standards for SI reports meet national guidance, to include: • Identifying the timescale to be examined in detail. • Review of root causes identified. • Carried out with the support of appropriate clinical advice. • Delivered within expected timescales. • Recommendations are outcome …
north_east_yorkshire
Independent investigation: Odessa Carey, Washington (2019) — Rec 4
a) The Home Office should incorporate learning about matricide and parricide into domestic abuse prevention strategies. b) Adult child to parent violence and mental illness should be incorporated into domestic abuse strategies.
north_east_yorkshire
Independent investigation: Odessa Carey, Washington (2019) — Rec 3
Northumberland County Council must ensure that a comprehensive domestic abuse strategy includes measurable outcomes from previous reviews.
north_east_yorkshire
Independent investigation: Nico Meli, Nottingham (2003) — Rec R3
Recommendations and action plans from the internal review. This report concludes that the trust’s system for ensuring the quality of action plans and their timely implementation was inadequate between 2004 and 2007. The trust has already taken steps to ensure that recommendations of serious untoward incident reviews and action plans …
midlands
Independent investigation: Kyle Maher, Tooting (2017) — Rec R9
The trust should ensure that those affected by an incident are offered support in a timely manner.
london
Independent investigation: Kyle Maher, Tooting (2017) — Rec R6
EIS should ensure that they engage all sources of information including families when trying to visit service users that are hard to engage.
london
Independent investigation: Khabi AbreyUnborn Baby, Westcliff (2016) — Rec 5
The Trust should put a system in place to ensure that internal investigation report findings are shared with service users, their families, and that other affected parties are taken into account.
east_of_england
Independent investigation: Khabi AbreyUnborn Baby, Westcliff (2016) — Rec 4
The Trust should assure itself that concerns submitted by families or members of the public regarding a patient are documented, subject to assessment and review, and where appropriate proactively acted on. In instances where action is not taken, the rationale should be documented.
east_of_england
Independent investigation: Kasey Gordon, Tottenham (2011) — Rec 5
The Trust should assure itself that the findings from Internal reports are acted upon in a timely manner.
london
Independent investigation: Kasey Gordon, Tottenham (2011) — Rec 3
The Trust should include an audit and/or process within the Internal Investigation action plan to ensure compliance with each recommendation.
london
Independent investigation: Enrique Parada- Blanco, Kingsbury (2008) — Rec 1
Internal Action Plan: The recommendations and action plan to be reviewed to take account oftheexternalinvestigationadditionalfindings.
london
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 13
Sefton Safer Communities Partnership should establish a clear and robust mechanism for ensuring that recommendations from Domestic Homicide Reviews and NHS Independent Investigations are systematically implemented, monitored, and evaluated across all relevant partner agencies. This should include regular reporting on progress and accountability for actions taken.
north_west
Independent investigation: Anne Morris, Troon (2012) — Rec 5
As part of its ongoing monitoring and evaluation of the implementation of the recommendations made by the internal review, the Trust should include stakeholder feedback – to answer the question: are these changes making a difference to service users, carers and staff?
scotland
Independent investigation: Abida Bi, Bradford (2010) — Rec 1
BDCT commissioned its own review of the CMHT under which Mr S was managed. The report of this review was published in March 2012. The Independent Team recommends that BDCT provides its commissioners with a detailed breakdown of its considerations of the recommendations made in this report and any actions …
north_east_yorkshire
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 3.4.2.3
That the Board reviews its arrangements for communicating with and listening to the experiences of the employees of The Christie.
Christie NHS Foundation Trust
north_west
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 3.3.1.3
The Trust should examine the feedback mechanisms from both staff and service users and seek assurance that all, regardless of their background (and particularly those from marginalised groups), are fairly and equitably represented when services are reviewed, and feedback is sought.
Christie NHS Foundation Trust
north_west
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 3.3.1.1
The Trust should seek feedback from BAME staff on their experiences and examine information provided in exit interviews f rom the last three years.
Christie NHS Foundation Trust
north_west
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 2.5.6.5
That the use and effectiveness of exit interviews be reviewed.
Christie NHS Foundation Trust
north_west
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 27
SHFT should have in place, as a priority, a mechanism for capturing the views and feedback of the service user, family member and carer about the entire SI investigation process. This should be monitored at regular intervals for learning purposes and should be shared with the central investigations team and …
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 16
SHFT must make swifter progress in developing the Patient Experience Dashboard to ensure that it is able to triangulate data and information effectively. It should consider using the data from the Triangle of Care processes to inform this Dashboard. It should also implement specific audits of carer feedback at a …
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Independent review of the care and treatment of Mr G — Rec 12
NHS England should review the national guidance in place to support the victims of serious incidents and mental health homicides, to develop a strategy to ensure health and social care providers offer appropriate support and engagement as required, both for recovery purposes and assurance that improvements have been identified and …
Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
Accepted
Independent review of the care and treatment of Mr G — Rec 11
The Trust should review its processes for engaging with third parties affected by the actions of its patients, with a view to ensuring a comprehensive and supportive communication pathway.
Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
Accepted
Independent review of the care and treatment of Mr G — Rec 10
The Trust should ensure all key stakeholders- including any victim of a patient related serious incident - have an opportunity to review and comment on a draft investigation report in advance of sign off.
Mr G published on the 16 th November 2021. Mr G was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
Accepted
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 69
Invited Service Reviews should include: • clear expectations for Royal College Invited Service Review Reports to be shared, in full, by the Trust with the relevant Trust Board; • expectations for when Royal College Invited Service Review Reports should be shared, in full, by the Trust with regulators; and • …
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Mr … — Rec 13
The Trust must ensure that communication from families is logged appropriately and that a timely response is given. The Trust must also ensure that information is given to carers indicating what other routes are available to them if they are not satisfied that their concerns are being taken seriously.
south_east
An independent investigation into the care and treatment of former … — Rec 5
As part of its ongoing monitoring and evaluation of the implementation of the recommendations made by the internal review, the Trust should include stakeholder feedback – to answer the question: are these changes making a difference to service users, carers and staff?
south_east
An independent investigation into the care and treatment of a … — Rec 2
NHS Somerset Clinical Commissioning Group must ensure that a system is in place to check that recommendations in investigation reports are fully reflected in associated action plans.
south_west
An Assurance Review of the Independent Review into the care … — Rec 1
The Trust must ensure that patient, family and carer voices are heard at every level of the organisation. The Trust must respond quickly when people experience difficulties with the services they receive and make lived experience voices central to the design, delivery and governance of its services. They have developed …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Independent investigation into the care and treatment of patient Y: … — Rec 3
Following a CRHTT referral, the referrer should receive feedback on the outcome of the assessment on the same day, and be informed if there are any changes to the original assessment time or date.
South Essex Partnership University NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Patient R: … — Rec 10
The Trust should test for effectiveness their implementation of the internal investigation’s recommendations, and ensure that the new model of care is operating fully and effectively by conducting some qualitative audits of the whole care pathway including for someone with personality disorder.
5 Boroughs Partnership NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Ms A — Rec 1
The recommendations and action plan of the Trusts internal investigation should be reviewed to take account of the External Independent Investigation Panel additional findings.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mrs A … — Rec 13
Oxleas NHS Foundation Trust and NHS Greenwich CCG should agree standards for outcome focussed recommendations following a serious incident, and standards for the level of evidence required for assurance before action plans are closed.
Mrs A and Miss B, published on 03 July 2019. Mrs A and Miss B was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr N — Rec 23
The North West London Collaborative of CCGs should revise the CWHHE Serious Incident Operational Policy (November 2016) against the requirements of the NHS England SIF to ensure that it meets with national policy and guidance with regard to the monitoring of action plans. It should also be explicit about the …
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec R3
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area through the Trust serious incident action plan group. Feedback from the family for the purposes of this review suggests that information for carers should include Section 17 leave and we …
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec R2
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Accepted
Independent investigation into the care and treatment of Mr J — Rec R1
In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.
Mr J, published on 25 August 2020. Mr J was in receipt of services from South London and Maudsley NHS Trust
london
Accepted
Independent investigation into the care and treatment of Mr E: … — Rec 8
NTW should undertake an evaluation of the impact of the changes that were introduced as a direct result of the SI’s recommendations.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Accepted
An independent review into the independent sector provider One to … — Rec 3
Engagement should continue regularly with wider stakeholders to obtain comprehensive and honest feedback on implementation and to inform any changes to a service specification.
north_west
An independent review into the care and treatment given to … — Rec 2
Where families ask the mental health service for support due to an ongoing deterioration in a loved-one’s mental health this should be proactively investigated, and families informed of the steps taken.
north_east_yorkshire
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 5
Support NIHR research into: How caregiver concerns are raised, received, and acted upon.
north_east_yorkshire
Independent reviews(50)
Ockenden Review — Rec LAfL 14.16
Improving Complaints Handling Complaints themes and trends should be monitored at the maternity governance meeting, with actions to follow and shared with the MVP.
Health & Social Care
Newman CAA Review — Rec 3.6
One of the NEDs should engage on a regular basis with the Chair of the CAA's consumer panel. Consideration should be given to direct NED engagement with the chair of other advisory panels and committees (for example, sustainability, finance).
Other
Newman CAA Review — Rec 3.5
The CAA's new consumer strategy should be approved by the board by 30 September 2023 and should be shared with the DfT and, ideally, published on the CAA's website. Work has already started on this. This strategy should include a commitment to invite the Chair of the CAA's consumer panel …
Other
Newman CAA Review — Rec 3.3
The CAA should improve its current mechanisms for engagement with stakeholders to ensure that there are opportunities for engagement on strategic priorities including policy, guidance and process changes. This should include consultation with stakeholders to help the CAA determine the appropriate level and form of engagement with different groups of …
Other
Litchfield WCA Review Year 5 — Rec 33
The SSA and Tribunal Service should continue working together to better define the information that would be most conducive to improving decision making without placing an undue burden on either organisation. Any enhanced feedback system should be extended to the Provider so that the performance of HCPs can also be …
Employment & Work
Litchfield WCA Review Year 5 — Rec 2
Use of 360° feedback and its impact on driving up the quality of decision making at all stages of the WCA process should be monitored over time and trends reported to the appropriate level to ensure that training needs are met and unintended behaviours are addressed. This work should be …
Employment & Work
Litchfield WCA Review Year 4 — Rec 35
Extend the feedback loop to ensure that learning is communicated to the HAP as well as to Decision Makers.
Employment & Work
Laming Review (Baby P) — Rec 41
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to ensure Serious Case Reviews focus on the effective learning of lessons and implementation of recommendations and the timely introduction of changes to protect children.
Other
Morecambe Bay Investigation — Rec 31
The NHS complaints system in the University Hospitals of Morecambe Bay NHS Foundation Trust failed relatives at almost every turn. Although it was not within our remit to examine the operation of the NHS complaints system nationally, both the nature of the failures and persistent comment from elsewhere lead us …
Health & Social Care
Morecambe Bay Investigation — Rec 13
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 to complainants. The Trust should increase public and patient involvement …
Health & Social Care
Harrington WCA Review (Year 3) — Rec 1
In order to improve the quality of decision making the Secretary of State for Work and Pensions asks the Tribunal Service for timely feedback on reasons for upheld appeals.
Employment & Work
Harrington WCA Review (Year 1) — Rec 11
The review recommends a better use of the reconsideration process.
Employment & Work
Wessely Review — Rec 98
An Organisational Competence Framework and Patient and Carer (Service User) Experience Tool should be implemented across health and care services. This should build upon ongoing work by NHS England to develop the Patient and Carer Race Equality Framework (PCREF).
Health & Social Care
Accepted
Darzi Review — Rec 19
Patient engagement. The patient voice is not loud enough. The NHS should aspire to deliver high quality care for all, all of the time. That not only means care that is safe and effective but that treats people with dignity, compassion and respect, making their experiences as positive as they …
Health & Social Care
Lammy Review — Rec 27
Prisons should adopt a 'problem-solving' approach to dealing with complaints. As part of this, all complainants should state what they want to happen as a result of an investigation into their complaint.
Justice & Legal
Accepted
Harrington WCA Review (Year 1) — Rec 15
The review recommends that feedback from the First-tier Tribunal should be routinely shared with Jobcentre Plus staff and Atos healthcare professionals. As part of their professional development, Jobcentre Plus Decision Makers should be encouraged to regularly attend Tribunals.
Employment & Work
Neurodivergence Task and Finish Group: report — Rec 9
Recommendation Nine: Develop clear and effective local routes to resolution when challenges occur Parents need to have a clear and effective local route to seek a resolution when complaints and challenges to accessing support occur, without incurring cost. Local Authorities and schools need to act on concerns without the need …
Health & Social Care
Newman CAA Review — Rec 3.4
The board should improve its level of engagement with the aviation industry to increase their and the CAA's visibility within the sector. In particular, there should be a programme for the NEDs to engage with specific stakeholders to increase internal and external visibility. The board is already taking steps to …
Other
Pickles Electoral Fraud Review — Rec R42
The learning from the work undertaken by local authorities in 17 areas at higher risk of electoral fraud ahead of the May 2015 polls should be utilised to inform guidance and practices that can assist areas in dealing with electoral fraud.
Other
Jones: Patronising Disposition Review — Rec 21
The response of South Yorkshire Police to criticism over Hillsborough has, over the years, included several examples of what might be described as 'institutional defensiveness'. The force's repeated failure to fully and unequivocally accept the findings of independent inquiries and reviews has undoubtedly caused pain to the bereaved families. I …
Policing & Security
Shape of Caring Review — Rec 2
NMC and HEE must incorporate the findings of recommendation one into future standard and quality assurance processes.
Health & Social Care
Harris Review: Deaths in Custody — Rec 96
NOMS should consider each PPO recommendation and any Coroners’ jury finding and PFD reports individually, decide whether it applies only to the establishment where a death occurred or more widely across the estate, and then put in place an appropriate action plan in response to that recommendation (which may involve …
Justice & Legal
Flanagan Review of Policing — Rec 28
Recognising that the Single Non-Emergency Number programme has acted as a catalyst for improved partnership working, the Home Office and CLG should ensure that learning from the programme is shared with all community safety partners and identify how to encourage and incentivise the mainstreaming of this approach into local operations. …
Policing & Security
Francis Inquiry (Mid Staffs 2010) — Rec 11
The Board should review the management structure to ensure that clinical staff and their views are fully represented at all levels of the Trust and that they are aware of concerns raised by clinicians on matters relating to the standard and safety of the service provided to patients.
Health & Social Care
Gloster Report (LCF/FCA) — Rec 4
the Senior Management of the FCA should ensure that product and business model risks, which are identified in its policy statements and reviews as being current or emerging, and of sufficient seriousness to require ongoing monitoring, are communicated to, and appropriately taken into account by, staff involved in the day-to-day …
Other
Hampton Review — Rec 4
All regulators should judge the effectiveness of their advice by monitoring business awareness and understanding of regulations.
Other
Selous Review — Rec 90
The Armed Forces Covenant Fund Trust to: • support the use of a range of robust, validated and appropriate evaluation tools to measure outcomes, benefits and the effectiveness attributable to each project/programme of work • consider the appropriateness and modifications needed to use the Outcomes Measurement Framework with UK Serving …
Other
Farmer Review (Men) — Rec 14
As part of their Performance Agreement each prison should establish a clear, auditable and responsive 'gateway' communication system for families and significant others: a dedicated phone line that is listened to and acted upon. • Families' concerns about mental and physical health should be systematically recorded and action taken. • …
Justice & Legal
MacAlister Review — Rec 65
Data and feedback should be used to prompt local and national learning to continually improve services. At a national level this should be via a National Practice Group and a National Reform Board. The evidence and learning landscape should be strengthened through the integration of overlapping What Works Centres, starting …
Education
Angiolini Review — Rec 101
An Office for Article 2 Compliance should oversee a coordinated, methodical and routine process around the dissemination of Coroners’ PFD reports and jury findings to all stakeholders, including (but not limited to) police forces, the College of Policing, the IPCC, and healthcare professionals.
Policing & Security
Accepted
Harrington WCA Review (Year 1) — Rec 18
The review has asked Mind, Mencap and the National Autistic Society to provide recommendations on refining the mental, intellectual and cognitive descriptors. The review looks forward to receiving these recommendations in late November and will make any recommendations it sees fit to Ministers.
Employment & Work
Harrington WCA Review (Year 1) — Rec 6
The review recommends that every claimant is sent a copy of the Atos personalised summary and is able to discuss any inaccuracies with a Decision Maker.
Employment & Work
Cunliffe Water Commission — Rec 85
Recommendation 85: Water companies should work with Water UK to disseminate innovation learnings across the water industry in England and Wales.
Other
Jones: Patronising Disposition Review — Rec 19
Families bereaved through public tragedy too often face a vacuum in respect of information about their rights and the process of an inquest. The Ministry of Justice's Guide to Coroner Services seeks to address this vacuum, but the evidence I have seen in producing this report demonstrates that more needs …
Policing & Security
Jones: Patronising Disposition Review — Rec 17
The government has not responded publicly to warnings about the state of pathology provision in England and Wales made in a 2015 Home Office-commissioned review conducted by Professor Peter Hutton, or to warnings made by the Chief Coroner in his 2015-2016 annual report. Both raise important concerns which government should …
Policing & Security
Carter Legal Aid Review — Rec 4.30
There should be no major changes in the current civil representation ex post facto remuneration scheme for the time being, but it should be kept under close review by DCA and the Legal Services Commission, together with the profession, and DCA and the Legal Services Commission should produce a report …
Justice & Legal
Carter Legal Aid Review — Rec 4.18
The Legal Services Commission should establish a best value tendered panel for very high cost criminal cases based on the steps sets out in paragraphs 80 to 89 of Chapter 4. Prior to doing so the issues set out in paragraph 90 of Chapter 4 should be consulted on with …
Justice & Legal
Carter Legal Aid Review — Rec 4.15
The Legal Services Commission should introduce a new graduated fee scheme for litigators in the Crown Court. The Legal Services Commission, during consultation and prior to implementation in April 2007, should ensure that the fees set out in Annex 4.6: • contain uplifts that appropriately reflect and remunerate differences in …
Justice & Legal
Carter Legal Aid Review — Rec 4.12
DCA and the Legal Services Commission should review the effectiveness of the October 2005 changes to the advocacy graduated fee cracks and guilties scheme in the Crown Court, and any changes proposed to this scheme, on the timing of cracked cases. This should report in January 2007 and be considered …
Justice & Legal
Carter Legal Aid Review — Rec 4.4
The Legal Services Commission should construct new General Criminal Contract working arrangements providing for access to own solicitor within and outside of contract areas and duty solicitor slots by January 2007 as set out in paragraphs 20 to 28 of Chapter 4. The new working arrangements should then be published …
Justice & Legal
Shape of Caring Review — Rec 18
Without duplicating existing data collections the NMC, in conjunction with HEE, should develop an annual undergraduate student nursing survey, with the results used to inform local and national improvement in both care practice and education delivery.
Health & Social Care
Shape of Caring Review — Rec 1
HEE should commission research to identify the forms of patient and public involvement that best support learning, and to ensure that patients and the public are utilised as a valuable resource.
Health & Social Care
Foster FE Review — Rec 37
The LSC should ensure that its planning, funding and performance management arrangements take full account of the voice of learners. It should introduce a requirement for FE colleges to collect learners' views on their learning and the learner environment in a consistent and systematic way as a key way of …
Education
Flanagan Review of Policing — Rec 18
The NPIA should work with forces on a post implementation review of the SOLAP workplace assessment and accreditation process, which the Greater Manchester Constabulary has offered to lead.
Policing & Security
Francis Inquiry (Mid Staffs 2010) — Rec 6
The Board should review the Trust's arrangements for the management of complaints and incident reporting in the light of the findings of this report and ensure that it: provides responses and resolutions to complaints which satisfy complainants; ensures that staff are engaged in the process from the investigation of a …
Health & Social Care
Walker Review — Rec 25
The board risk committee should be attentive to the potential added value from seeking external input to its work as a means of taking full account of relevant experience elsewhere and in challenging its analysis and assessment.
Other
Barker Land Use Planning Review — Rec 32
That DCLG publish a progress report on delivery against these recommendations by the end of 2009, drawing on the views of key stakeholders and users of the planning system. 170
Other
Berwick Review — Rec 8
All organisations should seek out the patient and carer voice as an essential asset in monitoring the safety and quality of care.
Health & Social Care
Morecambe Bay Investigation — Rec 34
The relationship between the investigation of individual complaints and the investigation of the systemic problems that they exemplify gave us cause for concern, in particular the breakdown in communication between the Care Quality Commission and the Parliamentary and Health Service Ombudsman over necessary action and follow-up. We recommend that a …
Health & Social Care
Morecambe Bay Investigation — Rec 24
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 and to receive personal feedback on the results. Action: the …
Health & Social Care
PHSO casework decisions(16)
P-004292 — Medway NHS Foundation Trust
Mrs F complained the Trust had not implemented promised actions following identified failings in her mother's care and treatment, causing a loss of faith.
NHS in England
Nov 2025
P-004652 — Wye Valley NHS Trust
The Trust has not implemented the service improvements it promised after previous care failings for her mother, causing ongoing anxiety during subsequent hospital admissions.
NHS in England
Jan 2026
P-001698 — The Royal Wolverhampton NHS Trust
Mrs O complained a locum consultant mismanaged her mother's treatment and The Royal Wolverhampton NHS Trust failed to implement Root Cause Analysis report recommendations.
NHS in England
Partly Upheld
Jan 2023
P-002847 — Birmingham and Solihull Integrated Care Board
Miss N complained the ICB failed to implement promised service improvements regarding her father's continuing healthcare and delayed arranging a meeting to discuss her concerns.
NHS in England
Upheld
Aug 2024
P-004406 — York and Scarborough Teaching Hospitals NHS Foundation Trust
A wife complained the surgical team failed to address her husband's deteriorating condition after ERCP surgery, leading to serious complications.
NHS in England
Dec 2025
P-003058 — Care Quality Commission
Mr and Mrs B complained the CQC failed to properly inspect a nursing home, act on intelligence, communicate effectively, follow enforcement policy, and resolve their complaints, causing distress.
UK Government
Partly Upheld
Oct 2024
P-002807 — North Cumbria Integrated Care NHS Foundation Trust
Miss L complained staff failed to escalate concerns about her baby's heart rate, denied a scan, missed placenta abruption signs, and delayed delivery, leading to her son's death.
NHS in England
Jul 2024
P-003482 — University Hospitals of Leicester NHS Trust
Mrs O complained the Trust failed to provide evidence of implemented procedural changes, updates, and options for her family, as promised in its previous complaint response.
NHS in England
Apr 2025
P-004392 — A practice in the Mansfield area
Mr R complained the Surgery dismissed his symptoms, provided inappropriate guidance, gave incorrect information about weight-loss injections, and poorly handled his complaint.
NHS in England
Dec 2025
P-003162 — Tameside and Glossop Integrated Care NHS Foundation Trust
Mrs N complained the Trust's account of service improvements was insufficient following missed antibiotic doses, lack of consultant input, and poor critical care decisions for her mother.
NHS in England
Nov 2024
P-003189 — An independent provider in the City of Bristol …
Mrs W complains a paramedic failed to correctly read her father's ECG and symptoms, leading to his death. She also alleges failures in subsequent training and information from the Trust.
NHS in England
Dec 2024
P-003768 — Portsmouth Hospitals University NHS Trust
Miss C complained the Trust didn't administer antibiotics before her baby's birth, despite her Strep B history, and ignored her concerns about jaundice before and after discharge.
NHS in England
Aug 2025
P-004713 — University Hospitals Birmingham NHS Foundation Trust
Miss A complained the Trust incorrectly applied glue and steri-strips to her son's facial wound and gave no aftercare advice, resulting in a permanent, aesthetically displeasing scar.
NHS in England
Upheld
Jan 2026
P-002533 — A practice in the Lincolnshire area
Miss R complained the Practice ignored her requests for pain relief and referrals, failed to examine her properly, and delayed treating her UTI, causing distress and pain.
NHS in England
Apr 2024
P-002566 — Guy's and St Thomas' NHS Foundation Trust
Mrs C complained the Trust wrongly discharged her from orthopaedic care, alleging staff did not listen to her symptoms of cauda equina, leading to ongoing mobility issues. She sought a substantial financial payment.
NHS in England
Apr 2024
P-001442 — Driver & Vehicle Licensing Agency
Mr O complained DVLA refused to change his V5C registration to 'motor caravan' despite compliance, and failed to clearly explain the reasons or requirements needed for approval.
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
Domestic Homicide Reviews(162)— showing 50 strongest matches
Enfield — recommendation 8
Enfield Community Safety Partnership should ask each agency involved in this review to provide feedback on their single agency recommendations.
Enfield Community Safety Partnership
West Berkshire — recommendation 1
It is recommended that comments about practice identified in the IMR should be considered by the relevant managers with a view to providing feedback to the staff concerned. Measure of success: All staff will be aware of the IMR, its findings and recommendations. Evidence that the report findings have been …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Basildon — recommendation 2
NHS England to share the findings from this Review, particularly drawing out the learning for General Practices, with those practices that were involved in the case.
NHS England
NHS England
Herefordshire — recommendation 2
Provide a Trust wide briefing on this case, detailing the observations, learning and recommendations from this individual management report. This will be communicated and Team managers will be directed to discuss in Team meetings.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Herefordshire — recommendation 1
Deliver a learning event to the teams involved in this episode of care delivery. This will provide staff with the learning from this review and give education on the actions.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Barnet — recommendation 5
The Home Office should forward copies of all DHRs involving a mental health component to the Secretary of State for Health & Social Care and the lead minister for mental health, for their consideration and to inform policy and decision making concerning community mental health and primary care service delivery.
Home Office
Home Office
Kensington and Chelsea — recommendation e
The Housing Operational Group to share domestic abuse best practice and learning with housing sales and legal conveyancing sectors
Housing Operational Group | VAWG Lead …
Kensington and Chelsea — recommendation e
The Children and Health Operational Group to identify GP surgeries and to share domestic abuse best practice and learning
Children and Health Operational Group
Leeds — recommendation LCCG1
Provide feedback to GP Practice
Leeds Clinical Commissioning Group
Harlow — recommendation 15.9.3
A victims and witness committee should be set up to operate under the Essex Criminal Justice Board. This needs to be set up as a multi-disciplinary group and can review any shortcomings and recommendations made by the other panels or committees.
CPS
Crown Prosecution Service
Hartlepool — recommendation 19
The Safer Hartlepool Partnership to share this DHR report with the Commission on Domestic & Sexual Violence and Multiple Disadvantage.
Safer Hartlepool Partnership
Hartlepool — recommendation 11
NHS England (North) share the MHHR report when finalised with the Safer Hartlepool Partnership to ensure co-ordination between relevant recommendations.
NHS England (North)
NHS England North
Bedford — recommendation 2
The CSP to work with partners in the BDAP to agree on a mechanism for collating and sharing findings and recommendations systematically from local DHRs.
Central Bedfordshire Community Safety Partnership | …
Croydon — recommendation 4
Croydon CCG, CHS and SLaM ensure that the learning from this case is disseminated to practitioners.
Croydon Clinical Commissioning Group | Croydon …
Croydon Clinical Commissioning Group
Somerset — recommendation 17.4.4
This agency to share the overall findings of the DHR with Emergency Department Staff
Taunton and Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Windsor and Maidenhead — recommendation 10
All agencies report progress on their single agency IMR recommendations to the Community Safety Partnership.
All agencies
Wiltshire — recommendation 2b
Triangulate with reduction in other agencies involvement.
NHS Wiltshire
NHS Bath and North …
Wiltshire — recommendation 2a
Monitor referral activity
NHS Wiltshire
NHS Bath and North …
Doncaster — recommendation 15
The findings of this review should be communicated to the RCGP clinical champions
NHS Doncaster | Doncaster Clinical Commissioning …
NHS Manchester Clinical Commissioning …
Doncaster — recommendation 11
Review current policy of feedback and monitoring of significant events in Primary Care and implementation of local policies by primary care staff to ensure that clinical governance is maintained. This could include domestic abuse, safeguarding children and adults, clinical care and interagency referrals.
NHS Doncaster | Doncaster Clinical Commissioning …
NHS Manchester Clinical Commissioning …
Blackburn With Darwen — recommendation 2
Findings of the report are fed back into the Professional Nursing Forum and AHP forums to support learning across all the services and recognition of the good practices identified
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Dorset — recommendation 6.11
The Chair of the Community Safety Partnership should bring the findings of this review to the attention of the MARAC Steering Group who will liaise with CAADA (Co-ordinated Action Against Domestic Abuse) to inform national guidelines.
Dorset Community Safety Partnership
Epping Forest — recommendation R14.
A member of the police investigating team to attend a review panel meeting at the earliest opportunity after the legal proceedings had been completed,
police investigating team
Basildon — recommendation 3
SETDAB and Kent Community Safety Partnership to integrate the learning from this Review into planning future awareness raising campaigns.
SETDAB | Kent Community Safety Partnership
Birmingham — recommendation 4
The Community Safety Partnership should ensure that revisions to the S11 and S175 audit safeguarding children audit tool incorporates learning from this and other domestic homicide reviews.
Community Safety Partnership
Harrow — recommendation 10
To ensure a delegate is identified in the action plan to feedback to the victim and that is it recorded as an action in the minutes especially where both the IDVA and referring agency are involved, or where there is no IDVA involvement and a victim is not engaging.
Hestia
Northampton — recommendation 10
New procedure to be created when concern cards are received that the Housing Officer arranges a meeting/discussion with the person who submitted the card to ensure they have a full understanding of the situation.
Northampton Partnership Housing
Nottingham — recommendation 6.3.2
That the organisation starts to use the feedback from their internal Case Audits to inform the development of future practice.
DLNR CRC
Probation Service
Milton Keynes — recommendation 3
The learning from this review should be brought together with the learning from other domestic homicide reviews in Milton Keynes to inform strategy and practice
SaferMK
Croydon — recommendation 4.2.5
Report on progress to date in relation to work in both schools and primary care which relate to recommendations and actions from prior reviews which are reflected and further understood in this review.
Safer Croydon Partnership
Islington — recommendation 9
Telecare Service should review their procedures relating to service users who refuse services to ensure this information is captured and systematically fed back to the referrer. To this end, the Telecare Service will work with Adult Social Care to further develop the IAS system to capture and report issues of …
Telecare Service | Adult Social Care
Islington — recommendation 6
MSW and ELiPSe team to review referral pathways, especially around how information about referrals to family services is communicated to clients and how referral outcomes are fed back to them.
MSW | ELiPSe team
Barnet — recommendation 1
This report should be shared with both practices.
Dr D1's practice | Dr D2's …
Cornwall — recommendation 21.15.2
The significant issues identified in the TFF Education IMR which relate to Lucy’s time at secondary school should be discussed in detail with the current management team at the school (which is under new management) and more generally with other Cornwall secondary school head teachers.
Cornwall Children’s Services - Together For …
Cornwall — recommendation 21.5.4
After publication of this Domestic Homicide Review’s reports, relevant Safer Cornwall cross agencies strategies and action plans should be reviewed to ascertain how they can build on the recommendations and action plans of individual agencies set out in this DHR.
Safer Cornwall Community Safety Partnership
Barking and Dagenham — recommendation 24
At the time contractors carrying out repairs, or at the annual inspection made by gas engineers, the housing officer should be updated within 24 hours where a property is found to be in an unacceptable condition.
Housing Department
Pendle — recommendation 5
That Lancashire and South Cumbria NHS Foundation Trust provides progress updates to Pendle Community Safety Partnership regarding their internal investigation action plan – these will be at 3, 6 and 9 months, with a presentation to the CSP at the 12 months’ stage to assure the CSP of progress, and …
Lancashire and South Cumbria NHS Foundation …
Lancashire and South Cumbria …
Pendle — recommendation 3
That Lancashire Constabulary provides an update to Pendle Community Safety Partnership on the action plan and learning from the recent DHR concluded in Blackpool in 2021.
Lancashire Constabulary
Lancashire Constabulary
North East Lincolnshire — recommendation 1
Provide feedback to the staff team regarding the impact and importance of ensuring the service recognises and responds appropriately to changing circumstances that may affect risk.
We Are With You
North East Lincolnshire — recommendation 4
The prison should provide a summary of learning for the reception and health care team and review operational guidance on checking for risk flags on community-based data systems.
The prison
Northumberland — recommendation CSC_F2
To review procedures relating to the feedback of information following multi-agency meetings, including TAF, to ensure that feedback is disseminated to all those actively working with the case.
Northumberland County Council (Children’s Social Care)
Oldham — recommendation 4
The Home Office should approach the Ministry of Justice to request further exploration of the following issues:- (i) how any relevant findings and learning from the completion of DHRs should be brought to the attention of the Office of the President of the Family Division; (ii) the circumstances, and process …
Home Office
Home Office
West Cumbria — recommendation SAR2
Cumbria Safeguarding Adults Board to use the findings of the above survey to inform the Mental Capacity ‘week of action’.
Cumbria Safeguarding Adults Board
Safeguarding Adults Board
Liverpool — recommendation 17.1.2
That Liverpool Community Safety Partnership requests evidence and assurances from agencies, as to how the learning from this case has been disseminated and embedded into practice. This could be achieved through the submission of a report that details how the learning has been embedded and the outcomes of case audits …
Liverpool Community Safety Partnership
Southampton — recommendation 9.2
That Southampton Local Authority harnesses the powerful messages expressed by this family concerning the impact the tragedy has had on them and their hopes for how families like theirs might be better helped in the future by working with them to produce a short video to be used by all …
Southampton City Council
Southampton City Council
Cumbria — recommendation 7.1.11
The three boards have developed guidelines for practitioners to strengthen and cultivate their curiosity around their practice. The guidance must be evaluated, and mechanisms put in place to assess its impact, including staff and patient feedback on its use.
Cumbria Safeguarding Children Partnership | Safer …
Cardiff — recommendation Recommendation One
That the outcomes of both the Child Practice Review and the Domestic Homicide Review are shared and considered by the Cardiff Public Services Board and any consistent themes are acted upon in a coordinated way.
Cardiff Public Services Board
Westminster — recommendation 6
Learning to be shared from these two local models regarding engagement with women with multiple needs
Safer Westminster Partnership
Rotherham — recommendation 17.6
The Safer Rotherham Partnership ‘near miss’ policy should be updated to require immediate notification to the DAPG via the DAC rather than delaying referrals to the next scheduled meeting.
Safer Rotherham Partnership
Rotherham — recommendation 17.2
The Home Office is invited to consider the current ‘near miss’ policy identified by the Safer Rotherham Partnership for wider dissemination and implementation.
Home Office
Home Office
CJINI inspection reports(10)
Belfast Harbour Police: A Follow-Up Review of inspection recommendations
Harbour and Airport Policing, Other Agencies and Organisati…
May 2010
Follow-Up Review of the PPS response to strategic inspection recommendations made between 2013 and 2015
Public Prosecution Service for Northern Ireland (PPS), Pros…
Feb 2018
Youth Conference Service: A Follow-Up Review of inspection recommendations
Youth Justice and Intervention, Children and Young People
Apr 2010
A Follow-Up Review of inspection recommendations on the Royal Mail Group Crime Investigations function
Inspections and prosecutions by Departments and other bodie…
Jun 2010
Hate Crime: The Follow-Up inspection of the management of hate crime by the criminal justice system of Northern Ireland
Hate Crime, Crime
Jul 2010
Enforcement in the Department of the Environment Northern Ireland: A Follow-Up Review of inspection recommendations
Inspections and prosecutions by Departments and other bodies
Nov 2011
Roads Policing: A Follow-Up Review of inspection recommendations
Policing, Policing and the Community
Nov 2010
The handling of Complaints – A follow-up review of inspections recommendations
Governance, The Criminal Justice System
Apr 2014
The effectiveness of youth conferencing
Youth Justice and Intervention, Children and Young People
Mar 2015
Anti Social Behaviour – A Follow-up Review
Other Crimes, Crime
Jun 2016