Healthcare support worker training
Lack of nationwide system and regulatory oversight for training standards of healthcare support workers.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
5 inquiry recs
29 PFD reports
5 committee recs
1 HSSIB rec
2 CQC actions
7 PPO recs
1 NAO rec
2 IMB recs
1 Article 2 learning point
1 detention investigation rec
5 DHR recs
2 PHSO decisions
29 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(5)
R73 — Band 4 associate practitioners
Recommendation: Consideration should be given to enhancing the post of healthcare assistant by creating Band 4 associate practitioners in both hospital and community settings in order to increase the skills of those providing the majority of direct care, and also to …
No response yet
R71 — Specialist training for healthcare assistants
Recommendation: All healthcare assistants working with people with learning disabilities and autistic people should be provided with training, which should include specialist learning disability training as well as basic positive behaviour support (PBS). They should be required to complete successfully an …
No response yet
R70 — Mandatory monthly clinical supervision
Recommendation: Clinical supervision (where individuals’ practice with individual patients is discussed) should be mandatory for all ward staff, including healthcare assistants, and should occur monthly. Clinical supervisors should be trained in the conduct of sessions and the outcomes for continuing development …
No response yet
COVID-M3.6 — Scale Up Hospital Capacity
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should work with trusts and health boards to ensure that pandemic plans include practical steps to rapidly scale up hospital capacity to treat acutely unwell patients. This should include …
Gov response: The government agrees with the Inquiry that it is important to continue to prepare to scale up hospital capacity and to regularly test this ability, ensuring that the system can respond effectively during a pandemic.
Accepted in part
2 — Review clinical staff competencies
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the skills, knowledge, competencies and professional duties of care of all obstetric, paediatric, midwifery and neonatal nursing staff, and other staff caring for critically ill patients in anaesthetics and …
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(29)
Jill Sinson
Concerns: The coroner noted insufficient regular monitoring by the GP and a Staff Nurse's assessment that lacked appropriate referral and review of medical records. Unsupervised monthly prescriptions of significant medication were also issued without due consideration of the deceased's self-harm history.
Overdue
Desiree Falvo
Concerns: Concerns were raised regarding insufficient A&E department cover for emergency surgical tracheotomy and inadequate training for clinicians in this procedure, impacting their skills and confidence.
Response (NHS England): • NHS England stated that A&E senior staff receive Advanced Trauma Life Support (ATLS) training in tracheotomies and needle cricothyroidotomy, repeated every four years. • A review of London Emergency … (AI summary)
Responded
Albert Flynn
Concerns: Care staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Response (Lester Aldridge LLP): • The organisation stated it would re-emphasise the need to call for qualified assistance during individual staff supervision and new staff induction. • Senior care staff involved in the incident … (AI summary)
Responded
Pamela Pattison
Concerns: The coroner identified deficient nurse training and understanding of Type 1 Diabetes, alongside a lack of specialist outreach nurse advice and insufficient consultant cover. Concerns also included staff unawareness of available equipment and a significant delay in patient transfer.
Overdue
Rio Andrew
Concerns: The report identifies a lack of regulation for private companies providing medical assistance at events, where medical knowledge was poor and CQC oversight was insufficient. It also highlights the unregulated status of 'ambulance technicians' and the absence of mentor suitability checks by private training providers.
Response (Association of Ambulance NHS): • The Association of Ambulance Chief Executives (AACE) has previously raised concerns with the Care Quality Commission (CQC) regarding the regulation of private ambulance providers at events. • AACE supports … (AI summary)
Response (Department of Health): • The Department stated its intention to consult on whether permanent providers of medical services at temporary events should be brought into the scope of Care Quality Commission (CQC) regulation. … (AI summary)
Responded
Ronald Volante
Concerns: The coroner raised concerns regarding the induction training for call handlers at Magenta Living Support Link, specifically on using a client's medical history and communicating changes in their presentation to emergency services. The report indicates a need to revisit the training manual and methods for call handlers.
Response (Magenta Living): • Magenta Living revised its procedures to ensure call handlers proactively share medical details with emergency services unless service users specifically advise otherwise. • Call handlers were briefed on a … (AI summary)
Responded
Margaret Rogerson
Concerns: The coroner noted a lack of staff training in patient feeding mechanisms, techniques, and associated risks, including no refresher training. Additionally, no training was available for family members on safe feeding practices.
Overdue
Thomas Ratchford
Concerns: The coroner noted concerns that carers used a hoist for pressure relief, a practice not recommended by healthcare professionals or manufacturers, and that staff lacked sufficient training in moving and handling and pressure relief.
Overdue
Simon Healey
Concerns: The coroner noted that private hospitals' NEWS policies for critically unwell patients may not align with emergency response guidance due to consultant availability. Also, general ward nursing staff may lack adequate training for complex post-operative care.
Response (IHPN): • IHPN began a learning programme with the Care Quality Commission (CQC) to promote best practice in safety and will discuss escalation policies with the CQC. • IHPN will undertake … (AI summary)
Overdue
John Doyle
Concerns: Insufficient training for occupational therapists on Telecare emergency equipment was identified, specifically regarding its availability, ordering process, and compatibility with home telephone systems. The coroner also noted a need for refresher training due to evolving technology.
Response (North East London NHS Foundation Trust): • A patient safety alert was issued on 10 July 2019, providing urgent action requirements for occupational therapists regarding pendant alarm assessments and compatibility checks. • A Telecare training session … (AI summary)
Overdue
Harrison Hassall
Concerns: The coroner raised concerns that newly qualified midwives may be permitted to work in the community without sufficient experience, noting this issue is not exclusive to one trust.
Response (Department of Health and Social Care): • Investigations by University Hospitals of Leicester NHS Trust and East Midlands Ambulance Service NHS Trust identified areas for improvement and resulted in recommendations for action. • The identified actions … (AI summary)
Responded
Roland Stannard
Concerns: The coroner noted insufficient knowledge and training among care home staff regarding specialist equipment for pressure sore prevention and treatment, leading to incorrect use or non-use. A further concern was the point at which social care should transition to nursing care.
Response (Dept. of Health and Social Care): • The Care Quality Commission (CQC) inspected Chilton Meadows Care Home in March 2021, rated it ‘Inadequate’, and placed it in special measures. • The Department outlined existing national frameworks … (AI summary)
Responded
Margaret Kinsey
Concerns: The coroner identified challenges in the Emergency Department due to a lack of night-time consultant cover and insufficient supervision for junior doctors, especially those new to the department. The report also noted inconsistent documentation of supervisory discussions between clinicians.
Overdue
Barrie Housby
Concerns: The coroner raised concerns regarding persistent staffing shortages at Clifton Hospital, a rehabilitation facility, which results in staff not having enough time to carry out expected tasks and places elderly and vulnerable patients at risk.
Overdue
Jos Tartese-Joy
Concerns: Concerns were raised about the lack of a national system to flag high-risk pregnancies and poor communication regarding induction plans. There was also a lack of clear guidance for student midwives on escalation processes and for staff on when to use admission CTG monitoring.
Response (Department of Health and Social Care): • The Department of Health and Social Care has announced funding and created an agreed format for online maternity records to improve communication and access. • NHS England is committed … (AI summary)
Responded
Joan Robinson
Concerns: The coroner identified concerns regarding the low completion rate of essential malnutrition screening training, noting it is not mandatory for all relevant staff. Additionally, the Trust's Nutrition and Hydration Committee is inconsistently supported and attended.
Overdue
Eclipse Morrison
Concerns: Concerns include the failure to identify risk factors in high-risk pregnancies, leading to insufficient consideration of elective Caesarean Sections. The coroner also noted gaps in training and escalation processes for junior doctors regarding appropriate mode and timing of birth decisions.
Overdue
Michael Waite
Concerns: Peabody support workers, providing 24-hour solo support in supported living accommodation, are not required to have certificated First Aid and Basic Life Support training. This absence of formal training for solo providers for vulnerable residents presents a risk of future deaths.
Response (Skill for Care): • Skills for Care is updating its Core and Mandatory training guidance, with republication due in spring 2024. • Skills for Care was commissioned to develop a new Care Certificate … (AI summary)
Response (Peabody): • Peabody introduced a revised training programme for care workers, which includes a certified Emergency First Aid course incorporating Basic Life Support. • New care workers will complete this enhanced … (AI summary)
Response (CQC): • The CQC commenced a responsive assessment of the service's training and learning culture, requesting details on actions taken by the provider. • The provider confirmed it revised protocols to … (AI summary)
Responded
Mark Pryor
Concerns: The coroner raised concerns that Health Care Professionals (HCPs) in police custody suites may not be receiving sufficient and adequate training to practice effectively or safely.
Response (CRG Medical Services): • The foundation training course for newly recruited Healthcare Professionals will be extended from two days to five days, effective from the 2024/25 financial year. • Clinical Leads and senior … (AI summary)
Response (The Faculty of Forensic Legal Medicine): • The Faculty has developed and published recommendations and guidance to support education and supervised training in Forensic Medicine, including for police custodial settings. • The Faculty contacted its membership … (AI summary)
Overdue
Tommy Gillman
Concerns: Insufficient paediatric nursing staff in the Emergency Department does not meet RCPCH standards, especially during high-pressure periods. The coroner also noted a lack of routine handover documentation and an unrobust system for recognising ill babies in ED.
Response (Sherwood Forest Hospitals NHS Foundation Trust): • The Trust has implemented core competencies for adult nurses caring for children, added a Band 5 RN shift, and introduced a new Band 7 supervisory Nurse in Charge role. … (AI summary)
Responded
Tracey Farndon
Concerns: Concerns were raised regarding the emergency department being overwhelmed and understaffed, impacting patient safety. Staff did not adequately consider a diagnosis of sepsis, nor did they fully understand the implications of unrecordable blood pressure and the importance of continuous observations for seriously unwell patients.
Response (Department of Health and Social Care): • The Department of Health and Social Care published a plan for recovering urgent and emergency care services, delivered 5,000 more staffed beds, and allocated £1.6 billion for discharge support. … (AI summary)
Response (University Hospitals Birmingham NHS Foundation Trust): • The Trust has implemented measures to improve patient flow, including creating a frailty Same Day Emergency Care area and an Emergency Observation Unit, and has significantly reduced reliance on … (AI summary)
Responded
Meha Carneiro
Concerns: The coroner raised concerns regarding insufficient trained paediatric nurses, a general lack of recognition of the child's severe illness by Emergency Department staff, and ineffective medical handovers with inadequate documentation of key information and clinical plans.
Response (Sherwood Forest Hsopitals NHS Foundation Trust): • The Trust has implemented a new supervisory Nurse in Charge role to provide 24-hour senior support and updated PEWS escalation guidance to ensure review by a minimum Tier 3 … (AI summary)
Responded
Angela Carpos
Concerns: Carers were unable to recognise aspiration pneumonia, and there was a lack of clarity regarding their training on this condition. The company witness could not confirm the trainers' qualifications or the contents of relevant policies.
Response (Mi Homecare): • MiHomecare updated its induction and refresher training to include additional clarity on aspiration, with the latest version due to go live. • The themed supervision relating to choking is … (AI summary)
Responded
Susan Pollitt
Concerns: The coroner identified gaps in the regulation of Physician Associates (PAs), noting the absence of a mandatory national framework for their training, supervision, and competency. The report also raises concerns about limited understanding of the PA role and a competency sign-off that omitted broader patient care aspects like consent.
Response (GMC): • The GMC confirmed that legislation for its regulation of Physician Associates (PAs) and Anaesthesia Associates (AAs) has received Royal Assent. • The GMC stated it will become the statutory … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians (RCP) has called for a limit in the pace and scale of the roll-out of Physician Associates (PAs) and asked NHS England to review … (AI summary)
Response (Faculty of Physician Associates): • The Faculty of Physician Associates (FPA) has lobbied successive governments for the regulation of Physician Associates (PAs) and contributed to the General Medical Council's (GMC) consultation on how regulation … (AI summary)
Response (Department of Health and Social Care): • Legislation was approved in early 2024 for the General Medical Council (GMC) to regulate Physician Associates (PAs) and Anaesthesia Associates (AAs) from December 2024. • The GMC has published … (AI summary)
Responded
Leslie Swindells
Concerns: Concerns were raised regarding a mental health assistant practitioner's limited training, insufficient understanding of risk, and unclear supervision. The report also noted inadequate patient triage, challenges with telephone assessments, and poor documentation.
Response (GTD Healthcare): • GTD Healthcare ceased the employment of Assistant Practitioners in Mental Health. • The organisation introduced a digital front door system for patient triage and reviewed induction processes for agency … (AI summary)
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England and the Care Quality Commission (CQC) regarding the concerns raised. • NHS England reviewed the concerns and provided information to the Department … (AI summary)
Responded
James Keen
Concerns: The coroner noted untrained support workers were conducting physical health checks with confusion about results and their interpretation, and there was no evidence of training or competency checks for this role.
Response (Revon Healthcare): • Revon Healthcare stated that support workers have received additional training specific to physical health monitoring, enabling them to conduct checks, understand normal ranges, raise concerns, and document findings. • … (AI summary)
Responded
Edward Funnell
Concerns: The coroner noted insufficient follow-up on a recommended podiatrist referral and a lack of knowledge among nursing staff regarding the purpose of such referrals and the importance of adhering to Tissue Viability Nurse dressing recommendations.
Response (Powys Teaching Health Board): • The Tissue Viability team updated their referral process and implemented a Vascular limb check observation chart. • The referral pathway to podiatry is being updated to ensure urgent referrals … (AI summary)
Responded
Alan Peet
Concerns: Concerns were raised regarding a nurse untrained in tracheostomy management being on a unit with patients requiring such care, and insufficient management oversight of staffing decisions. Additionally, the quality of care notes was poor, and an agency nurse lacked essential system access.
Overdue
Jean Waldron
Concerns: The coroner notes that a care agency team leader provided wound care despite clear instructions not to, raising concerns about inadequate training for carers on the limits of their care and adherence to specialist medical advice.
Response (Ignite Health and Homecare Services): • All staff received reinforced guidance clarifying that wound care and pressure sore management are outside the scope of carer practice. • Formal reminders were issued to staff regarding escalation … (AI summary)
Responded
Select committee recommendations(5)
#19 —
Recommendation: The Department and HEE highlighted the important role that apprenticeships and nursing associates play in widening access to the nursing profession, by enabling people to earn money as they train. In the case of nursing associates, which is a separate …
Response attribution not verified
#4 — Consult on amending regulations to give students and retired staff roles in immunisation.
Recommendation: To ensure that nobody misses out on vital vaccine protection because of practical challenges such as convenient times or locations, a more flexible delivery model, that makes the most of the wide range of healthcare professionals, is needed. We recommend …
Gov response: The Department of Health and Social Care (DHSC) is working closely with UKHSA and NHS England to improve access to our world-leading immunisation system and protect public health. This includes reviewing how the use of …
Position Not Stated
#20 —
Recommendation: In September 2020, NHSE&I estimated that it could need up to 46,000 additional staff to deliver the COVID-19 vaccination programme, including 26,000 vaccinators and 20,000 administrative staff. It planned to fill these posts through a combination of existing primary care …
Response attribution not verified
#16 —
Recommendation: We recommend that end of life care be included as a core skill for the generalist health and social care workforce, with a clear and defined set of competencies required to deliver high-quality and person-centred palliative and end of life …
Response attribution not verified
#15 — Ensure reformed dental contract fully utilises skills of the entire dental team.
Recommendation: The Government, NHS England and ICBs must ensure that the reformed contract ensures that full use is made of the skills of the whole dental team. (Paragraph 73) NHS dentistry 35
Response attribution not verified
HSSIB safety recommendations(1)
CQC inspection actions(2)
The Royal Oldham Hospital
The trust should consider reviewing the service’s healthcare support worker fill rates once the newly recruited staff are in post to determine if this has had a positive impact on the fill rates.
Should Do
Haisthorpe House
The provider must ensure people who used services are cared for and supported by staff that are appropriately supported by the provider to enable them to deliver care and treatment safely to people because staff have received appropriate training, professional …
Must Do
PPO death in custody recommendations(7)
The HMPPS Executive Director for Wales and the Chief Executive …
The HMPPS Executive Director for Wales and the Chief Executive of NHS Wales should write to the Ombudsman setting out what they have done to satisfy themselves that the nurse-led healthcare service provided at Parc by G4S Medical Services is …
The Head of Healthcare
The Head of Healthcare should ensure that all staff are competent and trained in blood pressure readings and management in accordance with NICE guidelines NG136 Hypertension in adults: diagnosis and management.
The Head of Healthcare
The Head of Healthcare should ensure that unregistered healthcare staff appropriately escalate changes in a prisoner’s weight to registered healthcare staff.
The Head of Healthcare
The Head of Healthcare should ensure that all members of the healthcare team receive supplementary training on their roles and responsibilities with regards to physical health checks and paperwork that should be completed when deciding whether a prisoner is fit …
The Governor and Head of Healthcare at HMP Durham
The Governor and Head of Healthcare at HMP Durham should ensure that all staff undertaking escort risk assessments understand the legal position on the use of restraints, that assessments fully take into account the current health, mobility and risk of …
The Head of Healthcare at HMP Berwyn
The Head of Healthcare should ensure that: healthcare staff working at Berwyn have timely access to advice, support and guidance from on call healthcare managers;
The Head of Healthcare
The Head of Healthcare should ensure that all patients who report that they feel clinically unwell, have a full set of clinical observations undertaken. They should also ensure that all staff are trained and competent in the use of the …
IMB individual recommendations(2)
Oakwood (2024)
The discharge lounge has previously provided good support to prisoners who are due for release and require specialist healthcare support, but it is not currently available due to staff sickness and vacancies. There is ongoing recruitment but has the Director any influence to expedite the process?
Governor / Director
Gatwick, Stansted, Luton and Lunar House (2020)
Detained individuals who are held for more than a very short period of time, should have access to a qualified medical practioner.
Home Office
Health investigations(2)
Independent investigation: Robert CrookElsie Crook, Swindon (2007) — Rec Ten
A quantitative and qualitative audit should take place to examine the supervision status of non-qualified staff. The findings of this audit should be used to revise the Clinical Supervision Policy. This audit should review: the percentage of non-qualified staff receiving clinical supervision; the number of sessions made available per annum …
south_west
An independent investigation into the care and treatment of Thomas: … — Rec 1
This case underlines the lack of expectation of residential care home staff to be able to deliver a range of physical health observations that individuals in a normal domestic situation either independently, or with the support of family/carers undertake at home. Objectively Thomas may have benefited from having his temperature, …
north_east_yorkshire
Article 2 learning points(1)
Independent reviews(19)
Willis Commission on Nursing 2012 — Rec 7
Governments, education institutions and employers must fulfil longstanding policy commitments to develop educational and employment models that widen access to nursing education, and provide career pathways for healthcare support workers including those who wish to train as nurses or midwives.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 6
A planned programme of regulation should begin with the mandatory registration of all staff who deliver patient care at Agenda for Change bands 3-4 (and their equivalents outside the NHS) by an independent regulator.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 5
All staff at Agenda for Change bands 3-4 (and their equivalents outside the NHS) who deliver patient care should be trained to NVQ level 3 as the minimum UK standard, delivered by healthcare providers and further education.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 4
The numbers and roles of healthcare support workers who deliver patient care must be properly planned and regulated, in the interests of patient safety and care quality.
Health & Social Care
Shape of Caring Review — Rec 12
HEE, in collaboration with employers and HEIs, should support the development of more innovative work-based learning routes. Those learning routes should be standardised to allow care assistants to move easily into the nursing profession without having to give up their employment, as they study and train for their nursing degree …
Health & Social Care
Shape of Caring Review — Rec 11
HEE should maximise existing collaboration opportunities and use funding levers to support HEIs that are willing to become centres of excellence. Care assistants should be offered APEL that could account for up to 50 per cent of the undergraduate nursing degree.
Health & Social Care
Shape of Caring Review — Rec 9
HEE should work with the care sector to develop or use an existing e-portfolio tool that will allow signed-off competencies to be recorded electronically on a national database for care assistants, across both the health and social care sectors. All competencies held within the database will be achieved at nationally …
Health & Social Care
Shape of Caring Review — Rec 8
HEE should explore with others the need to develop a defined care role (NHS Agenda for Change band 3) that would act as a bridge between the unregulated care assistant workforce and the registered nursing workforce.
Health & Social Care
Shape of Caring Review — Rec 7
NHS England should agree titles and job descriptions that align with HEE's development of a career and education framework for care assistants, as part of HEE's Talent for Care strategy for developing the health and social care support workforce.
Health & Social Care
Shape of Caring Review — Rec 6
HEE should set the competency standards for care assistants (NHS bands 1-4) in both health and social care, and work with employers to ensure the workforce is trained to meet those standards.
Health & Social Care
Shape of Caring Review — Rec 5
HEE should implement the Higher Care Certificate.
Health & Social Care
Shape of Caring Review — Rec 4
Subject to the outcome of recommendation three, any future government should ensure that the Care Certificate is a mandatory requirement.
Health & Social Care
Cavendish Review — Rec 13
Trusts should empower Directors of Nursing to take greater Board level responsibility for the recruitment, training and management of HCAs, from day one.
Health & Social Care
Cavendish Review — Rec 4
The NMC should recommend how best to draw elements of the practical nursing degree curriculum into the Certificate; HEE, LETBs and employers should seek to have nursing students and HCAs completing the Certificate together.
Health & Social Care
Cavendish Review — Rec 3
The Care Quality Commission should require healthcare assistants in health and support workers in social care to have completed the “Certificate of Fundamental Care” before they can work unsupervised.
Health & Social Care
Cavendish Review — Rec 2
A “Higher Certificate of Fundamental Care” should also be developed, linked to more advanced competences to be developed and agreed by employers. The Department of Health should hold HEE and Skills for Care to account for ensuring that there is step-change in the involvement of best employers.
Health & Social Care
Cavendish Review — Rec 1
HEE should develop a “Certificate of Fundamental Care”, in conjunction with the Nursing and Midwifery Council (NMC), employers, and sector skills bodies. This should be written in language which is meaningful to the public, link to the framework of National Occupational Standards, and build on work done by Skills for …
Health & Social Care
Shape of Caring Review — Rec 31
HEE should ensure that the funding for ongoing learning (and ongoing learning and career pathway qualifications in speciality learning) for care assistants and nurses becomes more transparent across the system.
Health & Social Care
Cavendish Review — Rec 11
Employers should allow HCAs to use the title “Nursing Assistant” on completion of the “Certificate of Fundamental Care”, where appropriate.
Health & Social Care
PHSO casework decisions(2)
P-001381 — Pennine Acute Hospitals NHS Trust
Mr U alleged a Healthcare Assistant incorrectly moved his son, aggravating a fractured femur and causing the need for surgery, resulting in a shorter leg and scarring.
NHS in England
Apr 2022
P-002757 — An independent provider in the South Gloucestershire area
Mr U complained an independent provider gave his daughter poor quality physiotherapy, harmful exercises, and inappropriate postural management, worsening her condition and causing irreversible damage.
NHS in England
Jul 2024
LGO / SPSO decisions(29)
202301731 — Forth Valley NHS Board
C complained about the nursing care and treatment provided to their parent (A) who was admitted to hospital after a fall. We took independent advice from a registered nurse. We found that there were unreasonable time gaps between care and comfort checks, making it impossible for the board to provide …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2024
202301629 — Fife NHS Board
C complained about the nursing care provided to their late parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2024
202301101 — Dumfries and Galloway NHS Board
C complained about the medical and nursing care and treatment provided to their late parent (A). A was admitted to hospital after repeated falls at home. A’s behaviour changed significantly during their admission which suggested that their mental state was deteriorating. C said that they were not directly informed of …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2024
24-009-630 — Onecall24 Healthcare Limited
Summary: We will not investigate this complaint about the Care Provider. Mr Y’s care is commissioned by the Integrated Care Board. Therefore, issues with his care are not administrative functions of the Care Provider, and we do not have the legal power to investigate them. The complaint must be made …
LGO (Local Government & …
Adult Care Services
Dec 2024
201101188 — Western Isles NHS Board
Mrs C made a number of complaints about the care and treatment provided to her mother (Mrs A) when she was admitted to the Western Isles Hospital for two days. We found that although staff had recorded that Mrs A was allergic to plasters, they continued to apply them to …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2012
201101177 — Tayside NHS Board
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection. We found that Mr …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2012
201301284 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained that her mother (Mrs A) did not received adequate nursing care at a hospital. We noted that the Procurator Fiscal had been involved and so we obtained information from them about their investigation. We found that the Procurator Fiscal had investigated Mrs A's nursing care and reached …
SPSO (Scottish Public Se…
Health
Dec 2013
201201876 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C was unhappy with the medical treatment and nursing care that her late mother (Mrs A) received in hospital over a two-month period. Mrs A was admitted to hospital with a fractured leg and suspected heart attack after a fall at home. Mrs A had an operation shortly after …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2013
201403176 — Highland NHS Board
Ms C complained about the care and treatment her late father (Mr A) received at the Royal Northern Infirmary. She said the board failed to provide adequate nursing care for her father and unreasonably failed to diagnose his broken collarbone and stroke. We obtained independent advice on the case from …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2015
201508155 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C's father (Mr A) was admitted to the Queen Elizabeth University Hospital. Mr A died there several days later. Mr C complained to us about Mr A's nursing and medical care and treatment during his admission. We obtained independent advice from a nurse and a consultant in the care …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201603071 — Forth Valley NHS Board
Mr C complained about the care his late wife (Mrs A) received from nursing staff during two admissions to Forth Valley Royal Hospital. On the first occasion she was admitted with sepsis (a blood infection) and on the second occasion she was admitted with a hip fracture. In particular, Mr …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2017
202004854 — Lanarkshire NHS Board
C made a complaint about the nursing care and treatment that their late parent (A) received at University Hospital Wishaw. C was concerned that A was not nursed in an elevated position and was kept lying flat. C also said that A's nutrition was not taken seriously and that the …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2022
202208120 — An NHS Board
C, a support and advocacy worker, complained on behalf of their client (A). A had undergone breast surgery to remove nodes and C complained that the board did not adequately assess and manage A's wound when it showed signs of infection. The wound deteriorated and A became critically unwell with …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2023
202207719 — Lothian NHS Board - Acute Division
C complained on behalf of their parent (A) who had been admitted to hospital with pneumonia. C complained that they found medication on the floor and in A's bedside cabinet. C complained that A's personal care needs had not been met, as they had not been washed and they had …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2023
202109772 — Grampian NHS Board
C complained about the nursing care that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2024
202202485 — Golden Jubilee National Hospital
C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated. In response to C’s complaint, the board acknowledged that documentation of …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2024
202201376 — Tayside NHS Board
C complained about the care and treatment provided to their parent (A). A had been admitted to hospital before being transferred to a mental health facility. A then developed abdominal symptoms, which required them to be transferred to an acute hospital for treatment. A had been considered for surgery, but …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2024
202201215 — Fife NHS Board
C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2024
202301849 — Fife NHS Board
C complained that the board failed to provide their late relative (A) with reasonable nursing care whilst in hospital. C told us that they felt nursing staff did not take A seriously when they reported pain, that information given was not passed to medical staff as agreed, and that A …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2025
201404703 — Lanarkshire NHS Board
Mrs C complained on behalf of her husband (Mr C) about his care and treatment in Monklands Hospital. In particular, she believed that an x-ray taken immediately before his admission showed sufficient evidence of respiratory problems that he should not have been allowed home, only to be admitted the next …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2015
201403703 — Lothian NHS Board
Mrs C complained that the board had failed to carry out appropriate investigations to identify the cause of her severe weight loss, decline in cognition and reduced mobility, when she was admitted to the Royal Infirmary of Edinburgh on two occasions. She said that staff only seemed to be interested …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2015
201508343 — Fife NHS Board
Mr C complained about the care and treatment of his late mother (Mrs A). Mrs A had multiple health problems and was admitted to Victoria Hospital with back pain. She was subsequently transferred to Queen Margaret Hospital but became unwell a few weeks later and was transferred back to Victoria …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2016
201508062 — Tayside NHS Board
Mrs C complained that her husband (Mr A) had received inadequate nursing care and treatment when he was a patient at Perth Royal Infirmary. Mr A had a number of health problems including diabetes and had previously had a toe amputated. He then had a major stroke and was transferred …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2016
201508215 — Grampian NHS Board
Mrs C raised a number of concerns about the palliative care that her mother (Mrs A) received. Mrs A had been diagnosed with terminal pancreatic cancer and was receiving care in her home from a multi-disciplinary team including her GP, district nurses and a Macmillan nurse. Once Mrs A's care …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2017
201608189 — Fife NHS Board
Mrs C complained about the care and treatment provided to her daughter by staff at the Victoria Hospital. Mrs C complained that when they arrived at the hospital, the nurse was unwelcoming and did not acknowledge how ill her daughter was. Mrs C also said that throughout the admission, nursing …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2017
201700463 — Lothian NHS Board - Acute Division
Ms C complained to us about the care and treatment her mother (Mrs A) had received after she was admitted to St John's Hospital with bipolar disorder (a mental health condition marked by alternating periods of elation and depression). Ms C complained about a number of issues in relation to …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2018
201705362 — Lothian NHS Board - Acute Division
Mrs C complained to us about the nursing care and treatment her mother (Mrs A) had received at the Western General Hospital after she had fallen and injured her head. Mrs C, who had power of attorney for Mrs A, was concerned about the nursing care she received. Mrs C …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2018
202101586 — Greater Glasgow and Clyde NHS Board - Acute …
C’s parent (A) lived in a nursing home and had been shielding during the COVD-19 pandemic. A was later admitted to hospital and was placed in a green pathway (a ward for COVID-negative patients) ward in preparation for emergency surgery. Following surgery and a few days in the High Dependency …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2022
202102718 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board failed to provide appropriate care for their parent (A). C said that the lack of care resulted in A falling from their bed, while the bedrails were in place. As a result, A fractured their hip. C said that staff had been made aware that …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2023
Domestic Homicide Reviews(5)
Sheffield — recommendation 3
Additional training to be delivered to GUM staff to include nursing assistants.
Nottingham University Hospitals NHS Trust
Nottingham University Hospitals NHS …
Forest of Dean — recommendation 4
The Home Office is asked to consider consulting with the Department of Health and Social Care and the Royal Colleges over whether stand-alone domestic abuse training should be made mandatory for all front-line health professionals.
Home Office | Department of Health …
Home Office
Dudley — recommendation Black Country Integr
Facilitate safeguarding training for all Practice Nursing Staff in Dudley.
Black Country Integrated Care Board
NHS Black Country ICB
Dudley — recommendation 4
Dudley Council to ensure that all front-line Adult Social Care staff, including carers, have been trained in identifying and responding to domestic abuse
Dudley Council
Dudley Council
Manchester — recommendation 10.1.4.2
Practice nurse’s role in enquiring about domestic abuse to be explored.
NHS Manchester Clinical Commissioning Group
NHS Manchester Clinical Commissioning …