Healthcare director fit person tests
Lack of robust 'fit and proper person' requirements and ongoing assessment for directors of healthcare providers.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
35 inquiry recs
5 PFD reports
16 committee recs
26 CQC actions
1 NAO rec
15 IMB recs
2 detention investigation recs
4 PHSO decisions
7 LGO/SPSO decisions
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(35)
35 — Clinical experience for managers
Recommendation: No clinician shall be appointed to a position of managerial authority in a hospital without having relevant clinical experience for the position.
Unknown
13 — Accountability and regulation of managers
Recommendation: i. DHSC and NHS England must develop and put in place a barring system for all managers (clinical and non-clinical) by September 2027. It should be reviewed in 2030 with a view to moving to a full statutory regulation system …
Gov response: It recommends new regulation on NHS managers, not just on clinical professionals. The government has consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians, so …
Accepted in part
F85 — Accountability of providers' directors
Recommendation: Monitor and the Care Quality Commission should produce guidance to NHS and foundation trusts on procedures to be followed in the event of an executive or non-executive director being found to have been guilty of serious failure in the performance …
Gov response: Accepted. In cases where a Director was deemed by the Care Quality Commission to be unfit, the Care Quality Commission would be able to insist on their removal by placing a condition on the provider’s …
Accepted
F84 — Accountability of providers' directors
Recommendation: Where the contract of employment or appointment of an executive or non-executive director is terminated in circumstances in which there are reasonable grounds for believing that he or she is not a fit and proper person to hold such a …
Gov response: Accepted in principle. In cases where there are reasonable grounds that a person is not fit to hold such a post, we would expect this view to be reflected in the references provided by the …
Accepted in part
F83 — Accountability of providers' directors
Recommendation: If a "fit and proper person test" is introduced as recommended, Monitor should issue guidance on the principles on which it would exercise its power to require the removal or suspension or disqualification of directors who did not fulfil it, …
Gov response: Accepted. Monitor and the Care Quality Commission are committed to ensuring that, taken together, their processes for registration and licensing work effectively to ensure that people in leading positions are fit and proper persons. The …
Accepted
F82 — Accountability of providers' directors
Recommendation: Provision should be made for regulatory intervention to require the removal or suspension from office after due process of a person whom the regulator is satisfied is not or is no longer a fit and proper person, regardless of whether …
Gov response: Accepted. Under the revised registration requirements, in cases where a Director was deemed by the Care Quality Commission to be unfit, the Care Quality Commission will be able to insist on their removal by placing …
Accepted
F81 — Accountability of providers' directors
Recommendation: Consideration should be given to including in the criteria for fitness a minimum level of experience and/or training, while giving appropriate latitude for recognition of equivalence.
Gov response: Accepted. We agree that people in leading positions in NHS organisations should have the appropriate experience and training to take up those positions and that this should be one of the criteria for any assessment …
Accepted
F80 — Accountability of providers' directors
Recommendation: A finding that a person is not a fit and proper person on the grounds of serious misconduct or incompetence should be a circumstance added to the list of disqualifications in the standard terms of a foundation trust's constitution.
Gov response: Accepted in principle. We agree that the public have the right to expect that people in leading positions in NHS organisations are fit and proper persons; and that where it is demonstrated that a person …
Accepted in part
F79 — Accountability of providers' directors
Recommendation: There should be a requirement that all directors of all bodies registered by the Care Quality Commission as well as Monitor for foundation trusts are, and remain, fit and proper persons for the role. Such a test should include a …
Gov response: Accepted in principle. We agree that the public have the right to expect that people in leading positions in NHS organisations are fit and proper persons; and that where it is demonstrated that a person …
Accepted in part
38 — Suitable calibre and training of managers
Recommendation: Hospital managers shall be of a suitable background and calibre for the role expected of them, provided with all necessary training (including continued education) and themselves regularly appraised for the quality of their performance.
Unknown
BRIS-94 — Appoint clinicians to managerial roles based solely on demonstrated competence
Recommendation: Clinicians should not be required or expected to hold managerial roles on bases other than competence for the job. For example, seniority or being next in turn are not appropriate criteria for the appointment of clinicians to managerial roles.
Unknown
BRIS-93 — Require managerial competence for clinicians appointed to managerial roles with training
Recommendation: Any clinician, before appointment to a managerial role, must demonstrate the managerial competence to undertake what is required in that role: training and support should be made available by trusts and primary care trusts.
Unknown
F232 — Employment liaison officers
Recommendation: The Nursing and Midwifery Council could consider a concept of employment liaison officers, similar to that of the General Medical Council, to provide support to directors of nursing. If this is impractical, a support network of senior nurse leaders will …
Gov response: Accepted. The Nursing and Midwifery Council have started planning the introduction of new regional advisors who will perform a function similar to the General Medical Council’s employer liaison advisers of providing support and guidance locally …
Accepted
F231 — Coordination with internal procedures
Recommendation: It is essential that, so far as practicable, Nursing and Midwifery Council procedures do not obstruct the progress of internal disciplinary action in providers. In most cases it should be possible, through cooperation, to allow both to proceed in parallel. …
Gov response: Accepted. The Nursing and Midwifery Council have made clear their view that their procedures should not obstruct internal disciplinary action, and that it would not expect the making of an interim order by the Nursing …
Accepted
F229 — Revalidation
Recommendation: It is highly desirable that the Nursing and Midwifery Council introduces a system of revalidation similar to that of the General Medical Council, as a means of reinforcing the status and competence of registered nurses, as well as providing additional …
Gov response: Accepted. The Nursing and Midwifery Council has committed to introducing a proportionate and effective model of revalidation, which is affordable and value for money, to enhance public protection. Subject to public consultation, the proposed model …
Accepted
F227 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: The Nursing and Midwifery Council needs to have its own internal capacity to assess systems and launch its own proactive investigations where it becomes aware of concerns which may give rise to nursing fitness to practise issues. It may decide …
Gov response: Accepted in principle. The Nursing and Midwifery Council are taking a different approach to achieving this recommendation. The Nursing and Midwifery Council is committed to working closely with the Care Quality Commission and with other …
Accepted in part
F226 — Nursing and Midwifery Council Investigation of systemic concerns
Recommendation: To act as an effective regulator of nurse managers and leaders, as well as more front-line nurses, the Nursing and Midwifery Council needs to be equipped to look at systemic concerns as well as individual ones. It must be enabled …
Gov response: Accepted in part. The Nursing and Midwifery Council have made it clear that they are determined to work closely with other regulators, including the Care Quality Commission to share information and analyses, and that it …
Accepted in part
F225 — Peer reviews
Recommendation: The General Medical Council should have regard to the possibility of commissioning peer reviews pursuant to section 35 of the Medical Act 1983 where concerns are raised in a generic way, in order to be advised whether there are individual …
Gov response: Accepted. The General Medical Council has made it clear that it is determined to work with others to explore the development of appropriate forms of joint ownership of generic issues, so that unacceptable patient care …
Accepted
F224 — Information sharing
Recommendation: Steps must be taken to systematise the exchange of information between the Royal Colleges and the General Medical Council, and to issue guidance for use by employers of doctors to the same effect.
Gov response: Accepted. The General Medical Council has made it clear that the exchange of information with Royal Colleges should be further systematised, and that it will take forward action to ensure that this takes place. The …
Accepted
F222 — General Medical Council Systemic investigation where needed
Recommendation: The General Medical Council should have a clear policy about the circumstances in which a generic complaint or report ought to be made to it, enabling a more proactive approach to monitoring fitness to practise.
Gov response: Accepted. The General Medical Council has made it clear that it recognises the need to contribute to the identification and in some cases the investigation of generic concerns, building on its progress in recent years …
Accepted
F86 — Requirement of training of directors
Recommendation: A requirement should be imposed on foundation trusts to have in place an adequate programme for the training and continued development of directors.
Gov response: Accepted. Monitor’s licence conditions require providers to ensure that no person who is an unfit person may become or continue as a Director and that they ensure that its contracts of service with its Directors …
Accepted
11 — Reconstitute the Hospital Management Committee
Recommendation: The present members of the Hospital Management Committee should be invited to resign and the Committee reconstituted. In view of the pressing need to reorganise services at Whittingham, a small committee of about eight should be set up pending the …
Unknown
BRIS-98 — Regulatory bodies to vary professional duties for full-time managers without patient care
Recommendation: The relevant professional regulatory bodies should make rules varying the professional duties of those professionals, whose registration they hold, who are in full-time managerial roles, so as to take account of the fact that, while occupying such roles, they do …
Unknown
BRIS-96 — Establish minimum clinical practice levels for clinicians in part-time managerial roles
Recommendation: To protect patients, in the case of clinicians who take on managerial roles but wish to continue to practise as clinicians, experts together with managers from the NHS should issue advice as to the minimum level of regular clinical practice …
Unknown
F228 — Administrative reform
Recommendation: It is of concern that the administration of the Nursing and Midwifery Council, which has not been examined by this Inquiry, is still found by other reviews to be wanting. It is imperative in the public interest that this is …
Gov response: Accepted. The Nursing and Midwifery Council has made clear its commitment to implementing the recommendations and achieving the required improvements in the delivery of its regulatory functions set out in the strategic review undertaken by …
Accepted
F223 — Enhanced resources
Recommendation: If the General Medical Council is to be effective in looking into generic complaints and information it will probably need either greater resources, or better cooperation with the Care Quality Commission and other organisations such as the Royal Colleges to …
Gov response: Accepted in principle. The General Medical Council has made it clear that it is determined to improve the way it shares information and works with other regulators and organisations such as the medical Royal Colleges. …
Accepted in part
F221 — Ensuring common standards of competence and compliance
Recommendation: Consideration should be given to ensuring that there is regulatory oversight of the competence and compliance with appropriate standards by the boards of health service bodies which are not foundation trusts, of equivalent rigour to that applied to foundation trusts.
Gov response: Accepted. The Care Quality Commission will be responsible for ensuring that all registered providers have appropriate and effective governance arrangements in place as part of its overall assessment of the health of the organisation. This …
Accepted
29 — Standards for manager quality responsibilities
Recommendation: Clear national standards should be drawn up setting out the responsibilities for clinical quality of other managers, including executive directors, middle managers and non-executives. All Trusts should provide evidence to the Care Quality Commission, as part of their processes, of …
Gov response: 57. We accept these recommendations in principle. 58. Following the tragedies at Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust there has been a renewed focus on leadership and …
Accepted in part
28 — National standards for clinical leads
Recommendation: Clear national standards should be drawn up setting out the professional duties and expectations of clinical leads at all levels, including, but not limited to, clinical directors, clinical leads, heads of service, medical directors, nurse directors. Trusts should provide evidence …
Gov response: 57. We accept these recommendations in principle. 58. Following the tragedies at Mid Staffordshire NHS Foundation Trust and University Hospitals of Morecambe Bay NHS Foundation Trust there has been a renewed focus on leadership and …
Accepted in part
14 — Review clinical leadership arrangements
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review arrangements for clinical leadership in obstetrics, paediatrics and midwifery, to ensure that the right people are in place with appropriate skills and support. The Trust has implemented change at …
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
19 — Professional bodies review conduct of registrants
Recommendation: In light of the evidence we have heard during the Investigation, we consider that the professional regulatory bodies should review the findings of this Report in detail with a view to investigating further the conduct of registrants involved in the …
Gov response: 5. We accept this recommendation. Action is under way. 6. The General Medical Council and the Nursing and Midwifery Council have emphasised that they have reviewed the findings of the Morecambe Bay Investigation Report and …
Accepted
IHRD-9 — Leadership Development
Recommendation: The highest priority should be accorded the development and improvement of leadership skills at every level of the health service including both executive and non-executive Board members.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-75 — Independent Disciplinary Action
Recommendation: Notwithstanding referral to the GMC, or other professional body Trusts should treat breaches of professional codes and/or poor performance as disciplinary matters and deal with them independently of professional bodies.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-14 — Clinician Competence Assessment
Recommendation: The experience and competence of all clinicians caring for children in acute hospital settings should be assessed before employment.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
16 — Clarify manager quality responsibilities
Recommendation: As part of the governance systems work, we consider that the University Hospitals of Morecambe Bay NHS Foundation Trust should ensure that middle managers, senior managers and non-executives have the requisite clarity over roles and responsibilities in relation to quality, …
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
Prevention of Future Deaths reports(5)
Kate Louise Pierce
Concerns: The coroner raised concerns regarding a doctor's fitness to practice, following a misdiagnosis and alleged misleading of parents about a second opinion, noting the doctor remains in practice.
Response (GMC): • The GMC stated it conceded a Judicial Review, which resulted in the closure of its investigation into past events due to statutory rules regarding events over five years old. … (AI summary)
Responded
Jack Postle
Concerns: The WGH maternity unit has insufficient capacity to provide safe patient care. Guidance for consultants restricts caesarean section availability by including a 'not as first choice' caveat, even after failed induction, without reference to clinical considerations.
Response (West Hertfordshire Teaching Hospitals NHS Trust): • A baseline audit of the Induction of Labour pathway has been completed. • The Induction of Labour Guideline is being updated to ensure the option for LSCS is given … (AI summary)
Responded
Peter Cole
Concerns: The coroner identified inadequate monitoring and supervision of repeat medication, leading to patients receiving dangerous quantities and widespread waste of healthcare resources.
Response (NHS England): • NHS England stated that Primary Care Networks are able to recruit clinical pharmacists to conduct structured medication reviews for patients with ongoing health problems. • NHS England is undertaking … (AI summary)
Responded
Joseph Price
Concerns: The coroner noted the absence of questions on reception health screens regarding family history of sudden cardiac death. Adding this to screening templates could help identify predispositions and prevent similar deaths.
Response (NHS England): • The prison healthcare provider for ten prisons in the North East and Yorkshire region added a question about family history of sudden cardiac death to secondary screening templates. • … (AI summary)
Responded
Gary Starbuck
Concerns: The coroner identified a lack of mandatory policy for private patients with high-risk Squamous Cell Carcinoma to be referred to a specialist skin MDT, unlike those treated in the NHS. This creates a risk of receiving inferior care compared to NHS patients.
Response (CQC): • The CQC has contacted two independent providers to seek reassurance regarding their processes for multi-disciplinary team referrals for cancer patients and their application of guidance. • The CQC's assessment … (AI summary)
Response (Royal College of Surgeons): • The College's existing guidance, including "Working in the Independent Sector: A guide to good practice" and "Good Surgical Practice", promotes equivalent standards of care and multidisciplinary working across NHS … (AI summary)
Responded
Select committee recommendations(16)
#12 —
Recommendation: We conclude that the Bill provides a timely vehicle to introduce reforms to the fit- and-proper persons test for appointments to NHS boards. We therefore recommend that the Bill is used to establish a UK-wide public register of people that …
Response status not verified
#14 —
Recommendation: The Government should require all practitioners performing invasive surgical cosmetic procedures to have specialist training and hold appropriate board certification in the procedures they undertake. (Recommendation, Paragraph 52) Non-surgical cosmetic procedures
Response status not verified
#13 —
Recommendation: Currently, any doctor on the medical register can legally perform highly invasive cosmetic surgery in the private sector, regardless of specialist training or competence. This is a risk to patient safety. Despite the introduction of the Intercollegiate Cosmetic Surgery Certification …
Response status not verified
#18 — TrustMark's registration process fails to adequately assess installer businesses' financial stability and liquidity.
Recommendation: The original installer is liable for fixing the installation to meet the relevant standards. However, the National Audit Office reported that not all installers are complying with the remediation process.38 We asked TrustMark whether the process for installer businesses to …
Response attribution not verified
#10 —
Recommendation: After taking into account his oral and written evidence, we are satisfied that Antony Jenkins has the appropriate professional competence and personal independence to undertake the role of external member of the Prudential Regulation Committee. We wish him every success. …
Response status not verified
#19 —
Recommendation: The Government should bring forward consistent, enforceable standards for the non-surgical cosmetic sector that prioritise patient safety and competency, while ensuring training routes remain accessible and affordable for a predominantly female-led workforce. Training routes should include Ofqual-approved qualifications and apprenticeship …
Response status not verified
#18 —
Recommendation: The absence of a legislative framework for training and qualifications in the non-surgical cosmetic sector has resulted in significant variability in standards, with justified concerns about short courses, online training, and the ease of entry into practice. (Conclusion, Paragraph 77)
Response status not verified
#17 —
Recommendation: The Government should accelerate regulatory action. Procedures that are deemed high risk such as liquid BBLs and liquid breast augmentations, which have already been shown to pose a serious threat to patient safety, should be restricted to appropriately qualified medical …
Response status not verified
#25 —
Recommendation: The Government should assess whether outlets in the UK that are recruiting patients for medical treatment overseas should be brought into a regulatory regime and be subject to investigation and, where necessary, sanction. (Recommendation, Paragraph 97) Body image
Response status not verified
#24 —
Recommendation: We welcome Government action on educating the public on the risks of travelling abroad for cosmetic procedures and providing guidance on how to do so as safely as possible and its use of social media channels to do so. With …
Response status not verified
#23 —
Recommendation: The Government should review the need for the NHS to systematically record data on complications arising from cosmetic procedures performed abroad. Publishing such data in an annual release would enable a comprehensive assessment of the financial impact on the NHS …
Response status not verified
#22 —
Recommendation: The increasing number of cases requiring medical treatment after cosmetic surgery abroad raises serious concerns for patient safety and places additional financial strain on the NHS. However, the true extent will remain unknown until comprehensive data is collected. (Conclusion, Paragraph …
Response status not verified
#21 —
Recommendation: The Government should work with the devolved administrations to ensure regulatory alignment across all UK nations on legislation governing non- surgical cosmetic procedures. (Recommendation, Paragraph 82) Cosmetic tourism
Response status not verified
#20 —
Recommendation: While Scotland has taken steps to introduce a licensing scheme for non-surgical cosmetic procedures, Wales and Northern Ireland have yet to announce similar plans. This lack of regulatory alignment across the UK creates significant risks, including inconsistent safety standards and …
Response status not verified
#16 —
Recommendation: However, the Government is not moving quickly enough in introducing such a system. At present, individuals without any formal training can carry out potentially harmful interventions, placing the public at risk. Successive Governments have failed to act swiftly enough to …
Response status not verified
#15 — Require the New Hospital Programme to conduct comprehensive live clinical testing of Hospital 2.0 designs.
Recommendation: Before the evidence session, we visited a “super hospital” project in Denmark. The Danes had built a prototype of a new operating theatre on the edge of an existing hospital and each surgical team was given access to it so …
Response attribution not verified
CQC inspection actions(26)
Sunderland Royal Hospital
The trust must maintain effective records to evidence adherence to the fit and proper persons regulation for directors.
Must Do
Sunderland Royal Hospital
The trust must ensure directors have an appropriate disclosure and barring service check and ensure this is repeated where required or the risks of not repeating checks are considered and assessed.
Must Do
South Tyneside District Hospital
The trust must maintain effective records to evidence adherence to the fit and proper persons regulation for directors.
Must Do
South Tyneside District Hospital
The trust must ensure directors have an appropriate disclosure and barring service check and ensure this is repeated where required or the risks of not repeating checks are considered and assessed.
Must Do
Scarborough Hospital
The trust should ensure that it follows the recommended period for repeating and recording Disclosure and Barring Service checks for directors.
Should Do
Salford Royal Hospital
The trust should ensure it effectively manages the administration of the fit and proper persons checks.
Should Do
Royal Preston Hospital
The trust should monitor the administration of files for the fit and proper persons checks.
Should Do
Rochdale Infirmary
The trust should ensure it effectively manages the administration of the fit and proper persons checks.
Should Do
Montagu Hospital, Mexborough
ThetrustshouldconsiderareviewofthetimescalesforDisclosureandBarring(DBS)re-checksforexecutiveandnon-executivedirectorstobeundertakensoonerthanevery10years.
Should Do
Cumberland Infirmary
The trust should ensure that it follows the recommended period for repeating and recording Disclosure and Barring Service checks for directors and that all qualifications are copied and recorded with in directors files. Regulation 5(3)(d).
Should Do
Chorley and South Ribble Hospital
The trust should monitor the administration of files for the fit and proper persons checks.
Should Do
The Walton Centre
The trust should improve the system for the capture and storage of information with regard to the Fit and Proper Persons Regulation.
Should Do
Fairfield General Hospital
The trust should ensure it effectively manages the administration of the fit and proper persons checks.
Should Do
The Christie Main Site
The trust must ensure there is an effective process to manage the administration of the fit and proper persons checks.
Must Do
Bridlington Hospital
The trust should formalise written guidance for fulfilment of the requirement of the Fit and Proper Persons Test (FPPT) for Directors.
Should Do
Medistaff24
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed
Must Do
10-12 Hainsworth Park
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed
Must Do
JDK Limited (Glenholme Care)
The directors have mismanaged the service and the regulated activity has not been carried out in compliance with the regulations. One of the directors has been unable to provide evidence of a DBS certificate.
Must Do
Floron Residential Home for the Elderly
This was a breach of regulation 19 (fit and proper persons employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Charlton House Medical Centre
On 27 September 2021 the newly appointed clinical lead emailed CQC to advise he had withdrawn from his role with the practice leaving no active clinical lead to direct clinical staff and to make clinical decisions, this placed patients at …
Must Do
Charlton House Medical Centre
There was no active or adequate oversight of GPs, GP locums and nurses working in the practice which continued to place patients at risk of harm.
Must Do
Manchester Court
The provider follows their staff recruitment policy closely with regard to the link to the guidance relating to Fit and proper persons employed.
Should Do
Kindered Hearts Limited
Regulation 19 HSCA RA Regulations 2014 Fit and proper persons employed
Must Do
Bridlington Hospital
The trust should continue its review of the Board members skills and prioritise its planned board development activities.
Should Do
Kingsleigh Residential
The provider had failed to ensure the registered manager had the necessary skills, competence and experience to manage the regulated activity.
Must Do
Regency Clinic - City of London
The service should have a patient eligibility criteria for the treatments offered.
Should Do
NAO audit recommendations(1)
IMB individual recommendations(15)
Springhill (2023)
Monitoring any new initiatives rolled out to enable the prison to better scrutinise the impact and quality of healthcare delivery and the health complaints system (6.1.3, 6.1.4 and 6.1.10).
Governor / Director
Downview (2023)
We reported previously that it was difficult to monitor the levels of complaints within healthcare as the system of recording appeared not to function adequately.
Governor / Director
The Mount (2021)
The Prison Service needs to review what lessons can be learned when evaluating tenders and planning for changes in healthcare providers.
HMPPS
Implemented
Wakefield (2022)
We ask the minister and his/her officials to explain how the ministry perceives the performance of prisoner healthcare at HMP Wakefield when compared against the performance specification in the contract.
Ministry of Justice
Noted
Norwich (2020)
The Board has been told that it cannot observe healthcare meetings and has not received copies of the minutes. The memorandum of understanding agreed with Her Majesty’s Prison and Probation Service allows Boards access to contract documents (see section 8.2).
Governor / Director
Huntercombe (2022)
To urgently replace the part of the healthcare facility which has water ingress and is therefore not a suitable working environment.
Governor / Director
Downview (2022)
It has been regrettable that there has been such a lack of stability with the management of healthcare during the reporting year and this has undoubtedly impacted on provision. We are reassured to see a permanent healthcare head appointed shortly after the end of the reporting period, which hopefully will lead to a more concerted effort on behalf of the …
Governor / Director
Bronzefield (2022)
What plans are in place to manage a smooth transition to the new healthcare services contract? (See paragraph 6.1.1.)
Governor / Director
Grendon (2023)
The Board looks forward to a monthly set of routinely collected/agreed healthcare data through which we can monitor the quality of healthcare.
Governor / Director
Grendon (2023)
The Board looks forward to monitoring any new initiatives rolled out to enable the prison to better scrutinise the impact of health delivery and the health complaints’ system.
Governor / Director
Gartree (2023)
We ask the Minister to explain how the Ministry of Justice perceives the performance of prisoner healthcare at HMP Gartree when compared against the performance specification in the contract.
Ministry of Justice
Gartree (2024)
The Board raised questions with the Minister last year about the quality and performance of service providers and remains concerned, particularly with regard to healthcare. So, we ask, again, how the Minister plans to address these issues?
Ministry of Justice
In Progress
Holme House (2021)
We would like to see the leadership team in the prison take an increased interest in healthcare complaints in a similar way to prison complaints. Responses to healthcare complaints did not meet their longer response timescales over several months and should be comparable.
Governor / Director
Frankland (2021)
Can HMPPS review the physical environment for healthcare, which is no longer sufficient for the size of the establishment?
HMPPS
Noted
Cookham Wood (2022)
Appointment of a permanent Governor: Is the YCS confident that appointment of a substantive postholder to the role of Governor at Cookham Wood can be made? Will there be adequate plans in place to support a smooth leadership transition when this eventually takes place?
HMPPS
Health investigations(7)
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R32
We recommend to the HC that it should use its powers of enforcement to ensure that, save in exceptional circumstances, no independent hospital is without a Registered Manager, who has been approved by the HC as a “fit person”, for a period of more than six months.
south_east
Investigation into matters relating to Jimmy Savile at Broadmoor Hospital — Rec (7)
Department of Health procedures proved inadequate in ensuring that the decision to give Savile a managerial role in 1988 was thoroughly evaluated and subject to proper scrutiny. In part, this was due to a combination of circumstances at the time that is unlikely to be repeated. We recommend that any …
West London Mental Health NHS Trust
london
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 68
The GMC should reflect on this investigation. They should: • seek to understand how and if team dysfunction issues impact on fitness to practice investigations; • determine whether the role of medical managers and their fitness to practice (in relation to their management function) have been sufficiently considered in this …
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 2
Seacole Ward should be subjected to a review by the Chief Nurse as a matter of urgency and a report submitted to the Trust Board and the Strategic Health Authority by the end of July 2005 so that the Trust can satisfy itself that conditions and clinical leadership have improved …
london
Investigation into matters relating to Jimmy Savile at Broadmoor Hospital — Rec (2)
Some celebrities may have the necessary qualities and the desire to contribute to the NHS in a non-executive capacity, but they should not be exempt from the usual selection process, which would include careful consideration of the benefits and risks. Celebrities should not be considered for operational or executive NHS …
West London Mental Health NHS Trust
london
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 71
The role of the RO and its development since the introduction of this function in 2010 should form a regular and consistent part of examination as part of internal and external Well-Led and governance reviews.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent review into the independent sector provider One to … — Rec 5
Professional integrity issues need to be investigated as a priority by commissioners and professional bodies when concerns are raised either informally or formally.
north_west
Detention investigations(2)
Review into the Welfare in Detention of Vulnerable Persons — Rec 21
I recommend that the Home Office immediately consider an alternative to the current rule 35 mechanism. This should include whether doctors independent of the IRC system (for example, Forensic Medical Examiners) would be more appropriate to conduct the assessments as well as the training implications.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 20
An action plan should be drawn up to address the shortcomings I found in healthcare facilities within the immigration estate to ensure a clinically safe, compliant and appropriate environment for the delivery of care to detainees.
Immigration Detention
Independent reviews(12)
Kark Fit and Proper Persons Review — Rec 7
We recommend that further work is done to examine how the test works in the context of the provision of social care and whether any amendments are needed to make the test effective.
Health & Social Care
Kark Fit and Proper Persons Review — Rec 5
The power to disbar directors for serious misconduct. We recommend the setting up of an organisation which will have the power to suspend and to disbar directors covered by Regulation 5, who are found to have committed Serious Misconduct (as defined in Recommendation 5.2 below (13.5.2)). In order to affect …
Health & Social Care
Kark Fit and Proper Persons Review — Rec 4
The FPPT should be extended to all Commissioners and other appropriate Arms-Length Bodies (including NHSI and NHSE)
Health & Social Care
Kark Fit and Proper Persons Review — Rec 3
The creation of a mandatory reference requirement for each Director. We recommend that full, honest and accurate mandatory employment references should be required from any relevant employer where an employee is moving from a post covered by Regulation 5 to a post covered by Regulation 5. Such references must not …
Health & Social Care
Kark Fit and Proper Persons Review — Rec 1
All directors (executive, non-executive and interim) should meet specified standards of competence to sit on the board of any health providing organisation. Where necessary, training should be available.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 33
All organisations providing cosmetic surgery should have a doctor on the Board as Medical Director who is professionally accountable for all work carried out by the provider organisation and for its procedures, practices and wider activity.
Health & Social Care
Francis Inquiry (Mid Staffs 2010) — Rec 9
In the light of the findings of this report, the Secretary of State and Monitor should review the arrangements for the training, appointment, support and accountability of executive and non-executive directors of NHS trusts and NHS foundation trusts, with a view to creating and enforcing uniform professional standards for such …
Health & Social Care
Kark Fit and Proper Persons Review — Rec 6
We recommend that, in relation to Regulation 5 (3) (d) of the Regulations, the words "been privy to" are removed.
Health & Social Care
Kark Fit and Proper Persons Review — Rec 2
That a central database of directors should be created holding relevant information about qualifications and history
Health & Social Care
Ockenden Review — Rec 4
Clinical governance – leadership. Essential action: Trust boards must have oversight of the quality and performance of their maternity services. In all maternity services the Director of Midwifery and Clinical Director for obstetrics must be jointly operationally responsible and accountable for the maternity governance systems. • Trust boards must work …
Health & Social Care
Accepted
Messenger Review — Rec 6
6. More effective recruitment and development of non-executive directors Establishment of an expanded, specialist non-executive talent and appointments team.
Health & Social Care
Cumberlege Review — Rec 8
Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors' particular clinical interests and their recognised and accredited specialisms. In addition, there should be …
Health & Social Care
PHSO casework decisions(4)
P-004569 — Charity Commission
Ms M complains the Charity Commission failed to properly investigate her case, closing it as "low risk" and not fulfilling its regulatory role.
UK Government
Jan 2026
P-003829 — Sheffield Children's NHS Foundation Trust
Ms P complained about inadequate care for her son, W, under a consultant, including poor monitoring and incorrect central line insertion. She also raised concerns about staff communication and complaint handling.
NHS in England
Partly Upheld
Oct 2023
P-003908 — Epsom and St Helier University Hospitals NHS Trust
Dr U complained a Trust nurse gave misleading information about her son, failed to update records with dietician letters, and sent false information to his school.
NHS in England
Jul 2023
P-002632 — Royal Devon University Healthcare NHS Foundation Trust
Mr H complained the Trust's paediatrician mismanaged his grandson's medication and lacked leadership, causing his mental health to deteriorate.
NHS in England
May 2024
LGO / SPSO decisions(7)
PSOW-202103154 — Meddyg Care Porthmadog
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
21-012-554 — London Borough of Enfield
Summary: We will discontinue our investigation into Ms A’s complaint. The Office of the Public Guardian is currently investigating concerns about Ms A acting as her daughter’s lasting power of attorney. We cannot say Ms A is a suitable representative for her daughter.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-011-337 — Southend-on-Sea City Council
Summary: We will not investigate this complaint about the Council’s investigation into whether a landlord was a fit and proper person to operate a house in multiple occupation. This is because Mr X has not been caused an injustice as a result of the actions of the Council.
LGO (Local Government & …
Housing
Upheld
May 2022
PSOW-202104666 — Pobl
Mrs A complained about the robustness and accuracy of a Stage 2 investigation undertaken by the Council into the care and support provided to her late mother (Mrs C) by an Extra Care Facility operated by Pobl. The Ombudsman commenced an investigation into the appropriateness of the Stage 2 investigation …
PSOW (Public Services Om…
Health
Apr 2022
PSOW-202308118 — Liberty Care Ltd
Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
22-008-209 — Bosence Farm Community Limited
Summary: We cannot investigate this complaint about the actions of Mr B’s Treatment Provider. This is because complaints about treatment provision are not within the jurisdiction of the Ombudsman.
LGO (Local Government & …
Adult Care Services
Dec 2022
201101678 — Greater Glasgow and Clyde NHS Board
Mrs C had fertility treatment which began in 2008. She had a successful pregnancy in 2009 and in 2011 was invited back for further treatment. On attending the appointment, she was advised there had been an administrative error, and she should not have been invited for further treatment as she …
SPSO (Scottish Public Se…
Health
Upheld
May 2012