Healthcare Professional Suicide Risk
High suicide rate among health service professionals, particularly GPs, indicating a need for greater awareness and preventative action.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
11 inquiry recs
22 PFD reports
32 committee recs
2 HSSIB recs
1 CQC action
2 HMICFRS recs
3 PPO recs
2 IOPC recs
2 PHSO recs
1 VC rec
21 IMB recs
13 IMB reports
1 Article 2 learning point
3 detention investigation recs
6 DHR recs
5 PHSO decisions
12 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(11)
9 — Debrief and support staff
Recommendation: The Chief Executive and Trust Board shall ensure the proper debriefing and support of all staff associated with a serious incident.
Unknown
5 — Support systems for child protection staff
Recommendation: Consideration should be given in all agencies where the need is recognised to the provision of an appropriate support system for those engaged in child protection work including those at managerial levels. Senior staff in Social Work Departments and Police …
Unknown
COVID-M3.10 — Healthcare Worker Support
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with healthcare employers and professional bodies, should put in place plans to deliver effective support for healthcare workers at scale from the outset of a pandemic. Plans should …
Gov response: The government will work in partnership with NHS organisations, healthcare employers and professional bodies to ensure that a clear and scalable programme of psychological support can be rolled out in the event of a future …
Accepted in part
5 — Consider urgent professional counselling
Recommendation: In devising a Serious Incident Procedure the Chief Executive and Trust Board shall consider the need for urgent professional counselling: – A proportion of individuals within any group is always likely to require psychological support in the aftermath of disaster. …
Unknown
4 — Training and services for stress
Recommendation: Consideration should be given to the development of training and services to deal with the levels of stress experienced in work in relation to child sexual abuse (15.18).
Unknown
COVID-M3.8 — Recording Healthcare Worker Deaths
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with their respective public health agencies and healthcare employers to develop nation-specific mechanisms to collect, analyse and publish data systematically on the deaths of healthcare workers in …
Gov response: The government agrees that, in the event of a future pandemic, data on healthcare worker deaths plays a vital role in supporting and protecting the workforce as well as improving epidemic surveillance. The government will …
Accepted
R36 — Medical staffing levels
Recommendation: Health Boards should ensure that the level of medical staffing planned and provided is sufficient to provide safe high quality care.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
SP35 — Balancing vulnerability with professional curiosity
Recommendation: Counter Terrorism Policing Headquarters should review and where necessary strengthen the training that Counter Terrorism officers involved in Prevent already receive to ensure that they understand the importance of balancing concern for an individual’s vulnerability with appropriate professional curiosity and …
Gov response: The Home Office is supporting CTP to make changes in relation to recommendations 32, 33 and 35 (2). These changes will improve case officers' ability to understand and assess the online activity of individuals referred …
Accepted
SP34 — Neurodiversity training for Prevent practitioners
Recommendation: Counter Terrorism Policing Headquarters should review its neurodiversity training for Prevent practitioners (including, where appropriate, drawing in wider healthcare advice) to ensure that they sufficiently equip practitioners with a proper understanding of: 1. How autism may influence risk in the …
Gov response: The internal strategic policy review of mental ill-health and neurodivergence in Prevent also includes recommended improvements to policy and training. The findings from this review will complement work by CTP in relation to recommendation 34 …
Accepted
BRIS-103 — Royal College of Surgeons to develop training and explore surgeon age limits
Recommendation: The Royal College of Surgeons of England should, in partnership with university medical schools and the NHS, be enabled to develop its unit for the training of surgeons, particularly in new techniques. It should also explore the question of whether …
Unknown
4 — Establish continuing professional development requirements
Recommendation: Following completion of additional training or experience where necessary, the University Hospitals of Morecambe Bay NHS Foundation Trust should identify requirements for continuing professional development of staff and link this explicitly with professional requirements including revalidation. This should be completed …
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(22)
John Davies
Concerns: The coroner noted that doctors undergoing General Medical Council investigations may experience adverse psychological effects that are unrecognised and unsupported. The report suggests considering communication tone, providing information on support agencies, and assessing for suicidal or self-harming behaviour.
Overdue
Lee Gaunt
Concerns: The coroner identified ineffective Occupational Health support and delays in accessing a doctor. Concerns were also raised about the Fire and Rescue Service requiring the deceased to take on extra duties despite knowing he was suffering, indicating insufficient support for staff in stressful situations.
Response (Lee Gaunt): • The Fire and Rescue Service (FRS) provided feedback on the inquest outcome and concerns to its current occupational health providers. • The FRS is piloting a Trauma Risk Management … (AI summary)
Responded
Joshua Blackham
Concerns: The coroner noted a lack of written policies defining the role of Welfare Officers and their training. Concerns also included improving communication channels regarding officer welfare and establishing a policy for the location of a serving officer's arrest.
Response (Surrey Police): • Surrey Police committed to providing training and refreshed guidance for Welfare Officers, including a video and revised documentation, with Senior Management Team oversight of Welfare Officers and Duty of … (AI summary)
Responded
Carl Sargeant
Concerns: The coroner noted that high-profile individuals removed from government roles, especially those attracting significant media interest, may not receive appropriate support channels, irrespective of their mental vulnerabilities.
Response (Welsh Government): • The Ministerial Code for the Welsh Government will be updated with a new section, 'Ministers and their Wellbeing,' to formally acknowledge the First Minister's responsibility for the wellbeing of … (AI summary)
Responded
Shaun Dewey
Concerns: The coroner raises concerns that the elevated risk of self-harm and suicide among remand prisoners is not adequately incorporated into staff training, highlighted to care teams, or reflected in national guidance and risk assessment documents.
Response (HM Prison and Probation Service): • HMPPS stated that it frequently supplements existing guidance with additional information for staff, including references to the increased risk posed by remand prisoners, and that training based on this … (AI summary)
Responded
Jaden Francois-Espirit
Concerns: The coroner noted that Jaden's deteriorating mental well-being was not recognised, preventing access to available support. The report highlights the importance of recognising subtle signs of distress and exploring a request for help that is subsequently not utilised.
Response (London Fire Brigade): • The London Fire Brigade (LFB) accepted 24 recommendations from its internal investigation report and developed an action plan. • The action plan was extended to incorporate concerns raised in … (AI summary)
Responded
Helen Spicer
Concerns: The coroner noted the absence of restrictions on the import, export, possession, or administration of oral morphine, and that safe custody requirements and signing for collection from pharmacies do not apply.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated it works closely with the Home Office and the Advisory Council on the Misuse of Drugs to inform decisions on controlled … (AI summary)
Response (ACMD): • The ACMD's Secretariat developed a standard operating procedure and a watch-list for medicines misuse. • The ACMD agreed to gather further information on the scale of the issue. • … (AI summary)
Responded
Kelly Hewitt
Concerns: The coroner identified a lack of mental health support available to prison officers and recommended a review of its provision.
Response (HM Prison and Probation Service): • The service employs an Employee Psychological Support Services Clinical Lead to oversee mental health support for staff. • A staff suicide prevention campaign was launched in September 2020 in … (AI summary)
Responded
Sarah-Louise Doyle
Concerns: The coroner noted that five-minute observations were recorded at precise, predictable intervals, which could allow individuals to anticipate timings and plan self-harm attempts. There were also concerns regarding a single signature covering multiple observations.
Response (Mersey Care NHS Foundation Trust): • Urgent instructions were issued regarding the use and recording of intermittent observations, emphasising unpredictable timing within observation windows. • A local audit was developed, and senior staff are conducting … (AI summary)
Overdue
James Forryan
Concerns: The coroner raised concerns about the easy accessibility of websites and forums that openly promote suicide methods, noting insufficient regulation and enforcement action against such platforms.
Response (Department of Health and Social Care): • The Government confirmed that the Online Safety Bill will require in-scope companies to remove illegal content, including that which encourages or incites suicide, and will list encouraging or assisting … (AI summary)
Responded
Susan Carling
Concerns: The coroner noted approximately 100 suicides occur annually within the health service profession. The report highlights the need for this issue to be addressed to prevent future deaths in this vulnerable professional group.
Response (Department of Health and Social Care): • NHS England, in collaboration with the Royal College of General Practitioners, launched coaching support services for primary care workers. • The Royal College of General Practitioners held a stakeholder … (AI summary)
Response (Royal College of General Practioners): • The Royal College of General Practitioners (RCGP) held a high-level stakeholder event in November 2022 to highlight the issue of suicide among health professionals. • The RCGP provides members … (AI summary)
Responded
Neil McDougall
Concerns: The coroner raised concerns about post-tour debriefing for serving personnel, which lacks 1-to-1 sessions. There is also no mandatory mental health assessment during the Army resettlement process for those leaving service.
Response (Ministry of Defence): • The Ministry of Defence (MOD) stated that a Structured Mental Health Assessment is conducted at the mandatory discharge medical for all service personnel, indicating that comprehensive mental health assessments … (AI summary)
Responded
Lee Winslow
Concerns: The coroner raised concerns that the Trust did not formally refer a doctor, who admitted taking medicines to end his life, to the Police or GMC. There was also a lack of meaningful external or multi-disciplinary review of the incident.
Response (Manchester University NHS Foundation Trust): • The Trust will convene regular, documented, senior-level meetings with Greater Manchester Police from October 2022 to standardise protocols and information-sharing. • The Responsible Officer will inform the General Medical … (AI summary)
Responded
Robert Stevenson
Concerns: The coroner raises concerns that current guidelines for Ciprofloxacin and Quinolone antibiotics do not sufficiently emphasise a potential rare link to suicide behaviour, noting that prescribing doctors may lack full awareness of this side effect.
Overdue
Barry Lall
Concerns: The coroner raises concerns about the level of detail published on the GDC website regarding allegations against dental practitioners before proceedings are concluded, noting a potential detrimental effect on individuals' mental health.
Response (General Dental Council): • The General Dental Council (GDC) had initiated a review of its guidance and policy concerning the publication of Interim Order outcomes and the conduct of public hearings. • Following … (AI summary)
Responded
Ruth Perry
Concerns: The coroner raised concerns about the impact of the Ofsted inspection system on school leader welfare, identifying a lack of Ofsted training and clear policies for addressing distress during inspections. The report also noted the absence of defined processes for raising concerns and conducting learning reviews after inspections.
Response (Ofsted): • Ofsted implemented mental health awareness training for all inspectors and introduced a new policy allowing inspections to be paused due to leader distress. • A national helpline was established … (AI summary)
Response (Department for Education): • The Department has implemented a process for schools judged inadequate solely for safeguarding to be re-inspected within three months. • Training has been delivered to officials on managing difficult … (AI summary)
Response (Reading Borough Council): • Reading Borough Council has committed to a more robust and proactive approach to Ofsted inspections, offering to challenge inspections on behalf of schools and identifying stress risks, which will … (AI summary)
Responded
Benjamin Sulzbacher
Concerns: The coroner noted a lack of understanding by Priory staff regarding available NHS community discharge services and a general lack of clarity across all services on whether private-paying patients could be referred to NHS discharge packages.
Response (Benjamin Sulzbacher Prevention of Future Deaths Report and Responses 2024): • The Department of Health and Social Care published statutory guidance for discharge from mental health inpatient settings and will consider clarifying its application to the independent sector. • NHS … (AI summary)
Overdue
Anugrah Abraham
Concerns: The coroner identified a lack of specialist mental health nurses in West Yorkshire Police's Occupational Health Unit and no post-death investigation into care quality. Concerns also relate to unclear procedures for officers disclosing suicidal thoughts and the impact of the Police Constable Degree Apprenticeship.
Response (West Yorkshire Police): • West Yorkshire Police confirmed that Occupational Health (OH) clinical staffing levels have improved, and the team is currently fully staffed. • The OH function will be subject to an … (AI summary)
Response (College of Policing and National Police Chiefs Council): • The College of Policing will introduce changes to the national programme specification for the Police Constable Degree Apprenticeship (PCDA) to strengthen wording and provide clarity. • These changes will … (AI summary)
Responded
John McLoughlin
Concerns: The coroner identified that the Peer Support system for pilots is insufficient for those with severe mental health difficulties, noting a lack of adequate support within the aviation industry for escalating mental health problems.
Response (Civil Aviation Authority): • The Civil Aviation Authority (CAA) will instruct Flight Operations and Approved Training Organisation Inspectors to encourage enhanced mental health support for pilots. • This encouragement will include upskilling peer … (AI summary)
Overdue
Wayne Brown
Concerns: The coroner identified a lack of policy at WMFS for investigating work-related deaths to learn about welfare support, and noted that existing wellbeing policies do not provide sufficient support for senior staff facing stressors or disciplinary investigations.
Response (West Midlands Fire Service): • West Midlands Fire Service will review its crisis management and death-in-service protocols to extend to employment-linked deaths and support for affected staff. • The Service will review and enhance … (AI summary)
Responded
Steven Davidson
Concerns: Healthcare staff at HMP Chelmsford experienced difficulties navigating System One records to find previous self-harm incidents, potentially due to insufficient awareness of the importance of searching these records and inadequate training.
Response (HCRG Care Group): • HCRG Care Group has amended its training provision to include structured SystmOne training for all new staff as part of their induction. • Refresher SystmOne training will be provided … (AI summary)
Responded
Benjamin Websdale
Concerns: The coroner noted the absence of local or national data on police officers who died by or attempted suicide during misconduct investigations. There were also concerns about inconsistent implementation of the "STEP" campaign for officers exposed to trauma.
Response (National Police Chiefs Council): • A paper recommending a requirement for consistent data reporting on police suicides to the Chief Medical Officer for policing was approved in March 2026. • A national approach to … (AI summary)
Responded
Select committee recommendations(32)
#26 —
Recommendation: The Royal College of Nursing noted that, to retain nurses who worked during the pandemic, it will be essential to provide access to specialised mental health support, carry out risk assessments for staff and ensure people are able to take …
Response attribution not verified
#25 —
Recommendation: NHSE&I acknowledged that there are worrying signs of stress and burnout amongst NHS staff since the COVID-19 outbreak. It cited figures from a Nursing Times survey, 56 C&AG’s Report, para 2.6. Based on England-domiciled applicants, UK universities, and includes midwifery …
Response attribution not verified
#6 —
Recommendation: The COVID-19 outbreak presents new challenges, as well as opportunities, for improving the recruitment and retention of nurses in the NHS. In particular, it is vital that the NHS protects the mental health and well-being of nurses who have contributed …
Response attribution not verified
#17 —
Recommendation: Covid-19 has exacerbated existing problems with staff welfare, but also brought some benefits, including higher levels of recognition and different ways of working. While enhanced recognition of the work of health and care staff is welcome, adequate and holistic support …
Response attribution not verified
#69 —
Recommendation: Alastair Sim, Director of Universities Scotland, told the Committee that the pandemic had also “been an incredibly difficult time for staff”.160 Dr Vicky Johnson stated that: [ … ] a lot of the senior management teams [ … ] are …
Response attribution not verified
#1 —
Recommendation: Burnout is a widespread reality in today’s NHS and has negative consequences for the mental health of individual staff, impacting on their colleagues and the patients and service users they care for. There are many causes of burnout, but chronic …
Response attribution not verified
#19 —
Recommendation: The mental health of farmers is one of the biggest challenges currently facing the sector. In October 2021, the Royal Agricultural Benevolent Institution reported that almost half of the farming community (47%) were experiencing some form of anxiety, and 36% …
Response attribution not verified
#21 —
Recommendation: The Government must introduce a dedicated, trauma-informed health pathway for all those affected by historical forced adoption. This should include improved access to specialist psychological support for birth mothers and adult adoptees, national clinical guidance recognising the heightened prevalence of …
Response attribution not verified
#19 — Increase mental well-being support for prison staff, building on existing services.
Recommendation: HMPPS should build on its existing management guidance and occupational health services to increase its support for the mental well-being of those who work in prisons.
Response attribution not verified
#10 —
Recommendation: We further recommend that the Department of Health and Social Care work with stakeholders to develop staff wellbeing indicators, on which NHS bodies can be judged.
Response attribution not verified
#101 —
Recommendation: We are concerned by the reports we heard about the impacts of fatal shootings which take place in rural communities in Scotland. It is clear to us that these communities should be provided with appropriate support where needed.
Response attribution not verified
#100 —
Recommendation: However, in relation to specific incidents, Reverend Gordon Matheson told us that “[t]here are issues around the subsequent trauma that people have experienced and accessing counselling care for that”.238 This issue is compounded by the relative lack of policing and …
Response attribution not verified
#9 —
Recommendation: The withdrawal from Afghanistan and end of the UK’s twenty-year military involvement in the country has understandably had a negative impact on veterans’ mental health. This has increased demand on services provided by organisations such as Combat Stress and Help …
Response attribution not verified
#7 — Create clear objectives and actions for agricultural and veterinary workers in national suicide prevention strategy
Recommendation: We are very concerned by the evidence indicating that agricultural and veterinary workers have a higher-than-average suicide rate compared to the rest of the population. Although more accurate information is needed, a clear enough picture Rural Mental Health 77 was …
Response attribution not verified
#6 — Joined-up public health approach essential for preventing suicide among agricultural and veterinary workers
Recommendation: Adopting a more joined-up approach to public health focused on early intervention could make a positive contribution to preventing suicide amongst agricultural and veterinary workers. It would need to ‘wrap-around’ people at potential risk, incorporating the NHS, other key public …
Response attribution not verified
#5 — Require DEFRA to establish a clear and active role in national suicide prevention strategy
Recommendation: DEFRA should be an active stakeholder in any national suicide prevention strategy, as the Department is responsible for populations and occupational groups arguably at higher-than-average risk of poor mental health and death by suicide. However, DEFRA does not appear to …
Response attribution not verified
#4 — Addressing risks and stressors for farming and veterinary workers represents an immediate priority.
Recommendation: In particular, the long list of risks and stressors affecting the farming community and veterinary workers is perhaps the immediate priority, not least because there are real opportunities for substantial gains in this area with significant levers for change in …
Response attribution not verified
#27 — Review and strengthen support mechanisms for school leaders' wellbeing during and after inspections.
Recommendation: The Department and Ofsted should review the support mechanisms available to school leaders during and following an inspection and ensure that these are as strong as possible to support the wellbeing of school leaders. Ofsted must publish a clear policy, …
Response attribution not verified
#25 — High-stakes inspection system causes significant stress and job insecurity for school leaders.
Recommendation: The ‘high-stakes’ nature of the current system is clearly causing a significant amount of stress and worry for school leaders. In particular, there is an overwhelming fear among headteachers that they risk losing their job following a less than ‘good’ …
Response attribution not verified
#17 — Existing data underscores the urgent need to improve support for terminally ill individuals.
Recommendation: We are pleased that the ONS in now attempting to monitor the rates of suicide for people with a terminal diagnosis, as this will facilitate scrutiny in the future. The existing data already serves as a sobering reminder that the …
Response attribution not verified
#16 — Committee expresses deep sadness over experiences of loved ones taking their own life.
Recommendation: We were extremely saddened to read and hear about the experiences of people who had experienced a loved one taking their own life, and our thoughts and deepest sympathies remain with them.
Response attribution not verified
#21 —
Recommendation: We further recommend that NHSE/I should develop a full and comprehensive definition of “workforce burnout”, and set out how the wellbeing of all NHS staff is being monitored and assessed. This information should be made available to us by the …
Response attribution not verified
#20 —
Recommendation: We recommend that NHSE/I set out in detail what further specific steps it would like to take over the coming years to support the mental and physical wellbeing of all staff and a plan to deal with the specific issue …
Response attribution not verified
#19 —
Recommendation: We are grateful for NHSE/I’s continued support of NHS staff and welcome the further measures set out in the People Plan (July 2020) for the 2020–21 period. In particular, we welcome the important and ambitious measures set out in the …
Response attribution not verified
#27 —
Recommendation: By October 2020, employers had reported 8,152 diagnosed cases of COVID-19 and 126 deaths as being linked to occupational exposure among health and care workers.45 The British Medical Association and Unison asserted that the Department should investigate whether PPE shortages …
Response attribution not verified
#56 —
Recommendation: The Foreign, Commonwealth and Development Secretary said the looting of health centres and destruction of vital infrastructure by Eritrean forces and other belligerents had led to “the disintegration of essential basic services and is exacerbating the parlous humanitarian context.”132 He …
Response attribution not verified
#52 —
Recommendation: Dr Christian Rogg, the FCDO’s Development Director for Ethiopia, echoed CARE International’s findings, telling us that most healthcare facilities were not functioning. He said restoring services would be challenging because facilities had been looted and personnel had left leading to …
Response attribution not verified
#50 —
Recommendation: People in Tigray have very little access to healthcare.115 Hospitals, health facilities, medical supplies and ambulances have been looted. Médecins Sans Frontières (MSF) estimated that barely 1 in 10 health facilities were functioning; of the 106 health facilities MSF teams …
Response attribution not verified
#10 —
Recommendation: We recommend a more precautionary approach is taken and a greater proportion of the money spent on elite sport is focussed on protecting the athletes who are at the core of UK success in sporting endeavours. We also recommend that …
Response attribution not verified
#15 —
Recommendation: The evidence we have taken leaves us in no doubt about the seriousness of the issues facing the food and farming sector caused by labour shortages. These include food security, animal welfare and the mental health of those working in …
Response attribution not verified
#7 — Mental health workforce experiences increased burnout and turnover due to staff shortages
Recommendation: We were also concerned about the impact of staff shortages on the welfare of the mental health workforce. Stakeholders told us about increased workload and pressure leading to “burnout” of remaining staff, contributing to a higher rate of staff turnover, …
Response attribution not verified
#31 —
Recommendation: We have heard distressing evidence on the effects on the mental health of people silenced by a non-disclosure agreement. The Government should consider the potential merits of a retrospective moratorium on NDAs for those that have signed them relating to …
Response attribution not verified
HSSIB safety recommendations(2)
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHS England and NHS Improvement investigates and evaluates the risks associated with the potential impact of staff fatigue and emotional distress on nosocomial transmission of COVID-19.
Safety Recommendation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to facilitate shared learning across the NHS so that effective strategies that have been adopted by local NHS organisations for the management of staff fatigue and emotional wellbeing can be shared.
Safety Observation
CQC inspection actions(1)
HMICFRS recommendations(2)
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Avon FRS isn’t looking after the wellbeing and mental health of its staff effectively. It hasn’t clearly communicated to staff the new values and how to demonstrate these values in the workplace. Recommendation: By 30 June 2019, …
Recommendation
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Avon FRS isn’t looking after the wellbeing and mental health of its staff effectively. It hasn’t clearly communicated to staff the new values and how to demonstrate these values in the workplace. Recommendation: The service should assure …
Recommendation
PPO death in custody recommendations(3)
The Head of Healthcare at HMP Berwyn
The Head of Healthcare should ensure that: appropriate measures are put in place to offer support to healthcare staff following their involvement in significant incidents.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff involved in a death in custody, and those that are identified as significant to the deceased, should be offered support in line with Postvention procedures.
The Governor of HMP Whatton
The Governor should ensure that staff receive adequate support following a death in custody.
IOPC learning recommendations(2)
Police investigation into serious sexual offences – Cambridgeshire Constabulary, July 2019
The IOPC recommends that Cambridgeshire Constabulary takes steps to ensure that sufficient wellbeing and welfare support are in place for officers and staff working in the Paedophile Online Investigation Team (POLIT). This should include considering: - psychological screening or assessment …
Recommendation - Avon and Somerset Constabulary, February 2025
The IOPC recommends that Avon and Somerset Constabulary take steps to ensure officers carrying out voluntary attendance interviews can access relevant guidance and support on suspect management, in particular how to mitigate the risk of self-harm and suicide in cases …
PHSO ombudsman recommendations(2)
Ignoring the alarms: How NHS eating disorder services are failing patients
Health Education England should review how its current education and training can address the gaps in provision of eating disorder specialists we have identified.
Ignoring the alarms: How NHS eating disorder services are failing patients
The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.
Victims' Commissioner recommendations(1)
IMB annual reports(13)
Isle of Wight (2023)
HMP Isle of Wight's population rose to 1,089 in 2023, operating at near capacity. The prison experienced a rise in deaths in custody (13) and violent incidents (191), although self-harm decreased. Key challenges included aging infrastructure, high staffing vacancies in OMU and healthcare, and inconsistent regime delivery for older prisoners, while positive developments were noted in education and integrated mental health services.
PRISON
Key concerns
Garth (2023)
HMP Garth, a Category B training prison, generally provides a safe environment, though self-harm and violence incidents increased. The Board's key concerns include persistent staff shortages impacting regime stability, key worker schemes, and offender management. The prison's physical estate is in poor condition, and delays in mental health transfers for complex cases remain critical. The IMB highlights the ongoing challenges of the IPP sentence and issues with prisoner progression and property transport.
PRISON
Key concerns
Gatwick IRC (2023)
The Gatwick IRC experienced a deterioration in safety during 2023, marked by increased violence, assaults on staff, and a rise in use of force incidents, partly attributed to a changing detainee population. Key safeguards for vulnerable individuals, such as Rule 34 and Rule 35 assessments, were found to be insufficient or subject to unacceptable delays. The report highlighted significant concerns regarding inadequate mental health provision, unfair regime practices including prolonged lock-in times, and a lack of effective pathways for release for detainees granted bail.
IRC
Key concerns
Liverpool (2023)
HMP Liverpool has shown positive progress in some areas, including education and the key worker scheme, but faces significant challenges. The Board is concerned by increases in self-harm, violence, and deaths in custody, compounded by high staff absence leading to regime closures. Major issues include inhumane delays in mental health transfers for segregated prisoners and a critical lack of accessible accommodation for those with disabilities.
PRISON
Key concerns
Leeds (2023)
HMP Leeds, a Category B local prison, faced significant challenges in 2023, particularly regarding overcrowding, which impacted shared cell conditions, and a concerning number of deaths in custody. The Board highlighted persistent issues with mental health provision, including transfer delays and a lack of secure beds, alongside ongoing concerns for IPP prisoners' progress and wellbeing. Staffing shortages and inexperience also posed challenges, affecting prisoner reception and key worker continuity, although efforts to improve training and staff-prisoner relationships in specific units were noted.
PRISON
Key concerns
Heathrow immigration removal centre (2023)
The IMB report for Heathrow IRC (2023) highlights increasing safety concerns, including a rise in self-harm (180 incidents), assaults (131 detainee-on-detainee, 54 on staff), and drug finds (104). The Board expresses significant concerns over the detention of mentally unfit individuals, the dilapidated infrastructure, and the misuse of segregation units. While health needs are generally met, staffing shortages and delayed Rule 35 responses remain problematic. The report also notes repeated concerns about prolonged detention times and the need for improved resettlement pathways for those on bail.
IRC
Key concerns
Lewes (2023)
HMP Lewes continues to face severe challenges, primarily driven by staff shortages that restrict the regime, leaving many prisoners out of cell for only an hour a day. This has contributed to significant increases in self-harm and assaults on staff, while issues with healthcare provision, mental health support, and the decency of accommodation persist. The Board highlights the disproportionate use of force against BAME prisoners and the ongoing lack of resettlement support for those on remand.
PRISON
Key concerns
Lancaster Farms (2023)
HMP Lancaster Farms, a category C resettlement prison, has largely provided a safe environment, though some pandemic regime restrictions were slow to lift. While primary healthcare is reasonable, mental health provision faces significant challenges due to staffing and a lack of specialist transfer capacity. Key worker contact and prisoner property management remain ongoing concerns for the Board, alongside issues of cell decency and delayed purposeful activity opportunities.
PRISON
Key concerns
Hewell (2023)
HMP Hewell, a Category B reception prison, faced severe overcrowding in the reporting year, with its population increasing to 1,060 and many prisoners sharing cells designed for one. This contributed to a significant rise in self-harm incidents and a persistent, restricted regime where most men are locked in cells for 22 hours daily. The report highlights ongoing challenges with staff shortages, inadequate key worker training, and delays in mental health transfers, alongside concerns about resettlement provision and the unmet needs of neurodiverse prisoners.
PRISON
Key concerns
Foston Hall (2023)
HMP/YOI Foston Hall has shown positive developments in regime provision and some safety initiatives, yet it continues to grapple with persistently high self-harm rates and increased use of force. Staffing shortages have impacted key work and overall experience levels, while healthcare faces challenges with recruitment, missed appointments, and inadequate facilities. The Board highlights significant concerns regarding accommodation decency, delays in parole and mental health transfers, and a lack of analytical focus on protected characteristics, affecting fair treatment and access to services.
PRISON
Key concerns
Full Sutton (2023)
HMP Full Sutton, a Category A and B high-security prison, operated with a population of 584 against an operational capacity of 594 at the end of 2023. The Board found it generally calm and well-managed, but tight staffing levels led to widespread rotational lockdowns, impacting purposeful activity and time out of cell. Key concerns include increased self-harm and violence, reduced drug testing capacity, and insufficient work opportunities, alongside delays in property distribution and a psychologist shortfall.
PRISON
Key concerns
Portland (2020)
HMP/YOI Portland, a Category C prison, faced significant challenges in delivering a stable daily regime, with frequent shutdowns impacting education and activity opportunities. While prisoner-on-prisoner assaults reduced slightly, overall violence remained high, and the prison struggled with drug ingress and staff shortages in mental health services. The Board noted concerns regarding poor building maintenance, staff attitudes towards prisoners, and issues with property transfers.
PRISON
Key concerns
Chelmsford (2021)
HMP/YOI Chelmsford, a Category B local prison, faced significant challenges during a reporting year heavily impacted by COVID-19 restrictions, leading to a restricted regime with limited purposeful activity and prolonged cell confinement. Key concerns included persistent overcrowding, a severe rat infestation, and substantial delays in handling prisoner complaints and property issues. The prison also struggled with staffing shortages, particularly affecting the key worker scheme and healthcare provision, alongside high self-harm rates and increased assaults on staff.
PRISON
Key concerns
IMB individual recommendations(21)
Moorland (2022)
Can the minister ask cabinet colleagues in the Department of Health and Social Care and the Treasury to address this shortage of beds?
Ministry of Justice
In Progress
Low Newton (2022)
The Minister should report on progress to increase the number of places available nationally in secure psychiatric units, since it remains the case that some women are being placed inappropriately in prison.
Ministry of Justice
In Progress
Berwyn (2020)
Healthcare representatives at good reviews
NHS / Healthcare Provider
Implemented
Swaleside (2022)
The Board is extremely concerned at the continuing low numbers of staff and the seeming inability to recruit. The inequality of pay and conditions when compared to other government agencies is certainly a factor in the cause of this issue together with the accessibility of the geographical area in which the prison is situated. The low numbers of staff severely …
HMPPS
In Progress
Leicester (2022)
Is the minister satisfied that there are sufficient secure hospital places to cope promptly with the demand?
Ministry of Justice
Nottingham (2023)
To address, with the health service provider, the issues raised in the provision of health care services, staff shortages and health care complaints.
Governor / Director
Eastwood Park (2024)
Address the serious issue of staff compassion burnout, injuries, and attacks from prisoners during restraints.
HMPPS
In Progress
Scotland and Northern Ireland short-term holding facilities (STHF) (2025)
Ministers should also mandate that immigration detention procedures at least meet the same standards expected of the police. A particular area in need of improvement is healthcare: Policies and practices: A senior clinician should oversee healthcare policies and practices, approving any departure from standards applied in police custody. This would ensure that practices such as the failure to require routine …
Ministry of Justice
Wymott (2020)
The Board remains concerned about the regular cancellation of prisoner forums, particularly the healthcare forum (see also section 3.4).
Governor / Director
Winchester (2021)
What is the prison service doing to hasten the upgrade to the healthcare bathroom and shower area which should be condemned? This work is very long overdue and the need for it was raised in our last two annual reports. (See section 6.3).
HMPPS
In Progress
Long Lartin (2024)
Prison staffing: following the changes to profiling towards the end of the year, what further measures are proposed to enable all aspects of the regime to operate across the prison (including healthcare)?
Governor / Director
Gartree (2024)
Since the appointment of a new healthcare provider, the Board is aware that there have been numerous complaints about healthcare provision and the response time for prisoner complaints (this has increased from 20 working days to 60 working days). What measures are in place to ensure an acceptable level of patient care is provided and maintained at Gartree?
HMPPS
In Progress
Gartree (2024)
The Minister has previously advised that healthcare provision is monitored and reviewed by NHS England Midlands Clinical and Quality Team. Despite numerous requests by the Board, the healthcare provider has steadfastly declined to provide any meaningful quantitative data for monitoring the healthcare provision and benchmark against the community equivalent. Again, we ask the Minister to explain how the Ministry of …
Ministry of Justice
Accepted
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
Durham (2025)
How does the Governor intend to ensure that all prisoners involved in UoF are seen by healthcare staff?
Governor / Director
Durham (2025)
How does the Governor intend to ensure that all prisoners involved in UoF are seen by healthcare staff?
Governor / Director
Derwentside (2022)
To introduce routine pregnancy testing for women detained in residential short-term holding facilities.
Home Office
Wealstun (2023)
To consider doing a check of the healthcare complaints process to address concerns relating to delays.
Governor / Director
Huntercombe (2023)
When will the Prison Service urgently replace the part of the healthcare facility that has water ingress and is not a reasonable work area?
HMPPS
In Progress
New Hall (2025)
Continued strategies to address the increase in number of complaints about the healthcare provision, e.g. plans for the women’s health hub and Practice Plus Group monitoring of health care centre concerns and complaints.
Governor / Director
In Progress
Erlestoke (2025)
While there has been considerable improvement in the attendance of healthcare at first ACCT reviews; just over one fifth still lack this essential input. How is this to be addressed, especially when reviews occur over weekends?
NHS / Healthcare Provider
In Progress
Health investigations(20)
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 3
The Department of Health should examine whether there are advantages to Occupational Health Services being provided across the NHS by Primary Care Trusts.
london
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 2
Recognise through appropriate expertise that 50% of the disabilities in employees are psychological and psychiatric in nature (Appendix 7.4) and some of those employees are in very mobile posts.
london
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 1
Resource staff in these departments to take appropriate responsibility for the care and support of staff and act as a supportive interface between their clinical needs and their employers.
london
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 2
Make recommendations on the nature and structure of services for doctors with physical or psychological illnesses.
london
Independent investigation: Freya Emson(3 mnths), NE London (2000) — Rec 4
The Royal College of Psychiatrists continues to have a particular role and responsibility to eliminate stigma towards mental illness within its membership and should take the appropriate action.
london
Assurance Review: Trust recommendations — Rec 46
Duty to monitor staff wellbeing The Trust has a duty to monitor staff stress levels and wellbeing and to intervene to support and understand the underlying issues before burn out affects patient care. The Trust should develop a cultural dashboard to identify key metrics that can provide early warning of …
north_west
This Independent Investigation into concerns and issues raised relating to … — Rec 51
All NHS organisations should ensure that they have robust processes in place to manage the impact of serious incidents and investigations on staff, including psychological support, fair process, and opportunities for learning and rehabilitation.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent investigation into the care and treatment of two … — Rec 3
The Trust must assure itself and its commissioners that front line staff receive appropriate support from managers both in hours and out of hours, when dealing with serious incidents.
north_east_yorkshire
Report of a review in respect of: Mr N and … — Rec 9
Stakeholders who have staff involved either directly or indirectly in, or with serious incidents, should have clear and confidential procedures in place to offer them appropriate and timely psychological and trauma support services.
wales
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 3
Strengthen cultural competence, psychological safety, and civility in practice.
north_east_yorkshire
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 3
Address the impact of work pressures, including rest breaks and downtime.
north_east_yorkshire
Independent investigation into the care and treatment of Mr S — Rec R9
Senior Trust managers should ensure post incident support continues so that as many staff members as possible use it.
Mr S, published on 16th December 2020. Mr S was in receipt of services from Central North West London NHS Trust
london
Accepted
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.7
We were told about the development of joint management/supervision arrangements for members of the CMHT and about ‘professional’ or ‘clinical’ supervision for various disciplines. We did not discuss arrangements for supervision or support for senior medical staff and we suggest that further consideration is given to developing methods of peer …
london
Independent investigation: Joan Smythe, Rainham (but SE Coast patient) (2002) — Rec 20.7
We were told about the development of joint management/supervision arrangements for members of the CMHT and about ‘professional’ or ‘clinical’ supervision for various disciplines. We did not discuss arrangements for supervision or support for senior medical staff and we suggest that further consideration is given to developing methods of peer …
south_east
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 8
The Co-Medical Directors should ensure that consultant psychiatrists have a well identified pathway to help and advice should they need assistance in any aspect of their work.
south_west
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 22
The trust should develop intelligent and targeted support strategies for staff after serious untoward incidents. (II/DB)
london
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 22
A clinical supervision network should ensure that individual staff are fully supported.
midlands
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 6
Porters should receive training and support about the transportation and handling of deceased patients. De-briefing and counselling should be available for porters who are adversely affected by carrying out this duty (source: chapters six and nine).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 17
The Trust should ensure that in future additional staff support is made available following serious incidents. Witnesses should be provided with a skilled approach to ensure: Counselling (if required); Support with statement writing; Support during interview; Support when analysing findings and implementing change.
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
An independent care pathway review of a young person: Published … — Rec 8
Trusts must ensure that group and individual reflective practice are essential parts of team development and must be facilitated when dealing with particularly challenging and complex patients.
london
Article 2 learning points(1)
Detention investigations(3)
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R4
The SMT at Gatwick IRCs must review arrangements for providing care and support to staff and ensure that they have ready access to a care service they trust. (To be completed within 3 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 16
A best practice forum should be established across IRC healthcare providers.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R28
The centre manager and senior Serco managers should continue to engage at all levels with NHS commissioners and G4S to ensure that concerns about the healthcare provision at Yarl’s Wood are addressed.
Immigration Detention
Independent reviews(5)
Stevenson/Farmer Review — Rec 17
We recommend that NHS England continues to develop its current offer on mental health in the Healthy Workforce Programme and other on-going initiatives, and look to ensure that every NHS Trust arms NHS employees with basic tools for prevention and self-care.
Employment & Work
Accepted
Mental Health Taskforce 2016 — Rec 33
NHS England should ensure current health and wellbeing support to NHS organisations extends to include good practice in the management of mental health in the workplace, and provision of occupational mental health expertise and effective workplace interventions from 2016 onwards.
Health & Social Care
Ockenden Review — Rec LAfL 14.14
Support for Staff The Trust must ensure that all staff are supported during incident investigations and consideration should be given to employing a clinical psychologist to support the maternity department going forwards.
Health & Social Care
Mental Health Taskforce 2016 — Rec 34
NHS England should introduce a CQUIN or alternative incentive payment relating to NHS staff health and wellbeing under the NHS Standard Contract by 2017.
Health & Social Care
Harris Review: Deaths in Custody — Rec 89
A meeting should be convened possibly chaired by Chaplaincy in conjunction with the local Samaritans, to come together and prove support to prisoners and staff following a self-inflicted death.
Justice & Legal
PHSO casework decisions(5)
P-004082 — Oxford Health NHS Foundation Trust
Dr V complained a Trust psychiatrist opened and deleted her email expressing concern for her husband before his suicide, and about the psychiatrist's demeanour at the inquest.
NHS in England
Sep 2025
P-004514 — A practice in the Gateshead area
Mrs G complained the Practice failed to reissue her morphine medication at the correct dosage and a receptionist prevented her from discussing suicidal feelings, leading to withdrawal symptoms and hospital admission.
NHS in England
Dec 2025
P-004047 — An independent provider in the West Berkshire area
Ms X complained a prison healthcare provider (PPG) failed to appropriately identify, monitor, and treat her eating disorder, causing her health to deteriorate and risking serious harm or death.
NHS in England
Sep 2025
P-001805 — South Tyneside and Sunderland NHS Foundation Trust
Mr R complained Trust staff stole his father's savings, intentionally overdosed him to end his life, and provided substandard treatment.
NHS in England
Feb 2023
P-002564 — Lancashire Teaching Hospitals NHS Foundation Trust
A nurse misgendered her, acted aggressively, and removed her ear defenders without permission, causing anxiety and impacting her mental health.
NHS in England
Apr 2024
LGO / SPSO decisions(12)
NIPSO-17293 — South Eastern Health and Social Care Trust
Our investigation found that the South Eastern Trust failed to properly assess the risks faced by a patient, and could have done more to help him before his death.
NIPSO (NI Public Service…
Health & Social Care
May 2021
NIPSO-202003166 — Northern Health and Social Care Trust
A woman complained about the care given to her husband in Antrim Area Hospital in the weeks before his death. We upheld parts of the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
NIPSO-202003845 — Southern Health and Social Care Trust
A man with Crohn’s Disease asked the Southern Trust to provide him with an additional bedroom and bathroom. We found the Trust’s decision to only approve a new bathroom was appropriate.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Apr 2024
PSOW-202309997 — Aneurin Bevan University Health Board
Miss D complained that Aneurin Bevan University Health Board failed to issue a response to her complaint, which she made to it in July 2023. The Ombudsman found that whilst the Health Board had initially dealt with Miss D’s concerns informally, it subsequently failed to log her concerns as a …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202400640 — Hywel Dda University Health Board
Ms V complained that Hywel Dda University Health Board failed to respond to a complaint she submitted in September 2023. The Ombudsman found that there had been a significant delay in the Health Board responding to the complaint. This caused additional frustration and inconvenience for Ms V. The Ombudsman decided …
PSOW (Public Services Om…
Health
May 2024
PSOW-202502304 — Betsi Cadwaladr University Health Board
Mrs H complained that Betsi Cadwaladr University Health Board failed to respond to a complaint she submitted in January 2025. The Ombudsman found that the Health Board failed to keep Mrs H updated for 5 months of its investigation. This caused additional frustration and uncertainty for Mrs H. The Ombudsman …
PSOW (Public Services Om…
Health
Oct 2025
PSOW-202504133 — Aneurin Bevan University Health Board
Miss A complained about the process in obtaining an autism diagnosis for her daughter and about the delay in receiving a response to her complaint (submitted in September 2024) from the Health Board. The Ombudsman found that the Health Board had failed to respond to Miss A’s complaint in a …
PSOW (Public Services Om…
Health
Oct 2025
PSOW-202101792 — Velindre University NHS Trust
Mrs A complained that the GP Practice (“the Practice”) failed to provide satisfactory care to her mother, Mrs B, and that this contributed to her rapid terminal decline in April 2020. Further, Mrs A said the Practice’s handling of her complaint was not adequate or robust. Mrs A also complained …
PSOW (Public Services Om…
Health
Upheld
Jun 2022
PSOW-202303635 — Betsi Cadwaladr University Health Board
Mr X complained about the lack of any contact or support from Conwy CMHT between June 2022 and February 2023 despite having a care and treatment plan in place. The Health Board accepted that, during this period there was no contact from the CMHT, and there were no care records …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202309096 — Betsi Cadwaladr University Health Board
Mrs D complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint about the care and treatment provided to her father which she made to it in August 2023. The Ombudsman found that the Health Board had failed to issue a complaint response and had …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202202910 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board had performed an operation to remove her mother, Mrs Y’s, knee replacement, and replace it with a temporary implant to aid the treatment of her infected knee, without the facilities to carry out the second stage procedure to fit a permanent …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202202910 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board had performed an operation to remove her mother, Mrs Y’s, knee replacement, and replace it with a temporary implant to aid the treatment of her infected knee, without the facilities to carry out the second stage procedure to fit a permanent …
PSOW (Public Services Om…
Health
Nov 2022
Domestic Homicide Reviews(6)
Lancaster — recommendation 4
To review the potential for isolation in the current environment of the Single Point of Access team in Lancaster and Morecambe – small office, lone working
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Forest of Dean — recommendation 5.2.5b
Review of the support needs of Social Workers and their managers working with parents who present with suicidal ideation.
Gloucestershire County Council Children’s Social Care …
Gloucestershire County Council
Southend-on-Sea — recommendation 11
CRI to ensure that staff members are provided with a safe environment in which to disclose any personal issues or risks and colleagues are able signposted to appropriate support.
Crime Reduction Initiatives (CRI)
Lincoln — recommendation 3a
The Safer Lincolnshire Partnership should ensure that those working with students are fully aware of the risks that academic pressure brings in relation to research highlighting this as one of the key risk factors in suicide and homicide.
Safer Lincolnshire Partnership
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation 2
The Safer Lincolnshire Partnership should ask the Lincolnshire Suicide Prevention Partnership to promote messages in relation to risks to others in particular family members from those individuals who are expressing self-harm and suicide ideation.
Safer Lincolnshire Partnership
Lincolnshire Partnership NHS Foundation …
Tower Hamlets — recommendation 7.1.10
Information about the availability of structured & clinical supervision to support colleagues who experience traumatic events at work, to be publicised as part of the Employee Assistance Programme.
Metropolitan Thames Valley Housing