Inaccessible multi-agency patient information
Critical patient information (e.g., 'familiar faces plans') being inaccessible to emergency services due to technology limitations.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
6 inquiry recs
28 PFD reports
15 committee recs
10 HSSIB recs
20 CQC actions
1 PPO rec
4 IOPC recs
45 IMB recs
2 Scottish FAIs
1 detention investigation rec
148 DHR recs
12 PHSO decisions
65 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(6)
165 — Reporter to obtain police information
Recommendation: An express statutory provision should be made enabling the Reporter to obtain from the police any information or articles held by them so that they may be available for the conduct of a proof under Section 42, subject to their …
Unknown
R93 — Regional service map with vacancies
Recommendation: There needs to be a clear regional view of all services available in the community, especially given the variety of services and providers of services now available. The service map recommended in 2022 must be regularly updated to reflect available …
No response yet
F35 — Need to share information between regulators
Recommendation: Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work …
Gov response: Accepted. The sharing of local intelligence between professional and system regulators in an appropriate and timely way is key to ensuring that risks to service users are identified and acted upon as needed. The Government’s …
Accepted
LAMI-32 — Ensure single, compatible electronic database for all children and families services
Recommendation: Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or …
Unknown
BRIS-29 — Require trusts to provide clear patient access to information and explanation
Recommendation: NHS trusts and primary care trusts must have systems which ensure that patients know where and to whom to go when they need further information or explanation.
Unknown
DM-20 — HOLMES access for independent panels
Recommendation: All independent panels and inquiries examining police investigations should be given full access to the associated HOLMES accounts at their secure premises when they begin their work.
Gov response: 2.3.14. The Panel was critical of the stance taken by the MPS as to practical access arrangements for sensitive material. There were – in addition – several issues with the Panel’s access to the MPS’s …
Accepted
Prevention of Future Deaths reports(28)
Dimitar Shtarbov
Concerns: The coroner identified that seasonal agricultural workers often lack awareness of how to access UK GP services, emergency numbers, and their entitlement to free care, leading some to obtain prescription medicines from their home countries.
Overdue
Audrey Kelly
Concerns: The coroner raises concerns that Out of Hours Service doctors and hospital Emergency Departments lack direct access to patients' electronic GP notes, noting this could lead to adverse patient outcomes.
Response (Department of Health2): • Mastercall confirmed that all relevant staff members now possess an NHS Smartcard. • Stockport CCG stated it would seek formal assurance from Mastercall regarding processes for new starters and … (AI summary)
Response (Department of Health): • The Department of Health described the national Summary Care Record (SCR) system and the local Stockport Health Record (SHR) system, which provide urgent and emergency care staff with access … (AI summary)
Responded
John Matthews
Concerns: The report notes that the triage nurse did not see the ambulance patient report form and a locum doctor lacked access to complete computerised patient information. There were also concerns that necessary neurological observations were not instituted and an unnecessary CT scan was performed.
Response (Stockport NHS Trust): • The Trust amended its induction training pack in November 2014 to provide clear instructions on accessing electronic ambulance documents. • The ED Matron re-iterated to nursing staff the importance … (AI summary)
Responded
Rita Paton
Concerns: The coroner raises concerns about the lack of a system to ensure requested blood tests are reported to GPs, and insufficient processes for patients lacking capacity to attend appointments. There is also a noted lack of readily available past medical and medication history for emergency crews.
Overdue
Vera Williams
Concerns: The report identifies a lack of a digital system for doctors and staff in the Emergency Department.
Overdue
Michael Brennan
Concerns: The coroner noted that a patient transfer backup plan relied on a bed that was unavailable, raising concerns that clinicians lacked real-time bed status information across the Trust's multiple sites when devising the plan.
Response (University College Hospitals NHS Trust): • The Trust stated it would amend its bed management policy by the end of May 2017 to include twice-daily updates on Westmoreland Street Hospital bed states. • The Trust … (AI summary)
Responded
Daniel Maher
Concerns: The coroner identified challenges in information sharing between mental health services in West Sussex and Surrey. Professionals cannot easily access patient data across county lines, and clinical records from s.136 assessments are not routinely shared.
Overdue
John Griffiths
Concerns: The emergency department lacked a system to check patients' recent presentations or admissions, which meant previous relevant records and investigation results were not routinely accessed.
Response (UHSM): • The Emergency Department system includes an alert on the patient's electronic record to identify previous attendances. • The Trust plans to enhance systems for identifying patient clinical history through … (AI summary)
Responded
Robert Brown
Concerns: Information about prisoners was not consistently available across different prison systems and to all relevant staff, leading the coroner to seek an update on the national development of a unified information system and its implementation timeline.
Response (the Director General of Prisons): • Development work on phase one of a project to automate patient administration data from NOMIS to SystmOne has been partially completed. • Phase three of the project, which includes … (AI summary)
Responded
Lee Thrumble
Concerns: The coroner noted that not all clinical staff in prisons can access the NOMIS system, which holds critical prisoner information, because training for it is not compulsory for them. This lack of access to information puts prisoners at risk.
Overdue
Felicity Clough
Concerns: The coroner identified challenges with information sharing due to a lack of interoperability between patient record systems across NHS trusts. Additionally, police forces lack automatic mechanisms to share welfare and health information about individuals.
Response (Secretary of State for Health and Social Care Minister for Crime and Polici): • NHS England reported that 41 of 42 Integrated Care Systems have implemented a basic shared care record solution and committed to achieving national interworking by 2023/24. • Yeovil District … (AI summary)
Overdue
Ketheeswaren Kunarathnam
Concerns: The coroner noted a disparity in information and advice for detained prisoners awaiting deportation, with limited access to support and ineffective communication between the prison and Home Office regarding their cases.
Response (Home Office): • HM Prisons and Probation Service issued an instruction in November 2021 to provide individuals held under immigration powers in prison with access to 30 minutes of legally aided immigration … (AI summary)
Responded
Daniel Ludlam
Concerns: The NHS Pathways triage system does not adequately account for patients with learning disabilities, lacking specific procedures to ensure accurate symptom communication and appropriate triage. This gap risks delays in care, particularly for callers without a carer to assist.
Response (Department of Health and Social Care): • Health advisors and clinicians receive core training on engaging with people with learning disabilities, and NHS Pathways staff competency is monitored. • NHS Pathways includes functionality such as 'Early … (AI summary)
Overdue
Derek Larkin
Concerns: The coroner identified a lack of interoperability between Dorset Council Adult Social Care's Mosaic system and NHS SystemOne, limiting Adult Social Care's access to crucial patient medication information and review dates.
Response (Dorset Council): • The learning recommended from an action plan was shared with relevant managers in February 2023. • Dorset Council stated that in future cases, Health would be consulted on medication … (AI summary)
Response (NHS Dorset ICB): • The Dorset Care Record (DCR) provides health and social care staff with access to individual patient medication and review information. • The DCR has been available since February 2018 … (AI summary)
Responded
Stephen Cassidy
Concerns: Clinical staff at SMH lack routine access to patients' Summary Care Records, which are not integrated with the hospital's electronic patient record system. This absence of critical patient information means doctors may be unaware of important details, such as allergies.
Response (NHS England): • NHS England is working with North Bristol Trust to identify alternative solutions to smartcards for staff access to Spine services. • NHS England's Summary Care Records team and digital … (AI summary)
Response (NHS North Bristol NHS Trust): • The Trust has trialled non-smartcard access to the National Care Record Service (NCRS) and plans to make it available to all staff in the first quarter of 2024. • … (AI summary)
Responded
Andrew Bowles
Concerns: The mental health liaison nurse lacked direct access to hospital records, leading to an assessment without critical information about a patient's command hallucinations and self-harm thoughts. This gap in record sharing between services may affect future patient safety.
Response (Birmingham and Solihull Mental Health NHS Foundation Trust): • Following a joint meeting, regular bank staff within the Psychiatric Liaison Team will be allocated direct access to hospital records. • Agency staff working single shifts will be advised … (AI summary)
Responded
Paul Gander
Concerns: The coroner noted that a consultant surgeon could not access electronic records from other hospital departments during weekends and out-of-hours, highlighting the importance of full access for authorised personnel.
Overdue
Evie Davies
Concerns: The coroner noted a lack of real-time information sharing between the cafe71 service and the mental health team, meaning cafe71 staff lack access to patient background and risk factors, and mental health teams are not notified of contacts.
Response (Cheshire and Wirral Partnership NHS Foundation Trust): • Crisis line staff received a reminder to ensure referrals between services contain contact information and to complete warm transfers with patient consent where possible. • Café 71 updated its … (AI summary)
Response (Cheshire and Merseyside Integrated Care Board): • The Integrated Care Board (ICB) confirmed it had liaised with Cheshire and Wirral Partnership NHS Foundation Trust (CWP) to confirm information sharing arrangements. • The ICB stated it would … (AI summary)
Response (Spider Project 1): • The respondent stated that the individual did not contact Cafe 71 directly. • The respondent clarified that Cafe 71 operates as a non-clinical safe cafe space, not a crisis … (AI summary)
Response (Spider Project Cafe): • Referral forms for Café 71 were made more detailed to include consent for leaving voicemails. • Referral forms now request information on other referrals or support provided to the … (AI summary)
Responded
Liam McCarlie
Concerns: Mental health professionals in the Emergency Operations Centres lack access to patient mental health records held on SystmOne, despite EMAS having access to GP records on the same system. This information could be crucial for triage and dispatch of ambulance resources, particularly for patients with a history of suicidal ideation.
Response (EMAS and Northamptonshire ICB): • A 24/7 mental health crisis service was established in late 2023 to provide ambulance services with access to mental health practitioners. • EMAS continues to include 24/7 mental health … (AI summary)
Responded
Sophie Wilson
Concerns: The ambulance crew and paramedic were unaware of the deceased's multi-agency 'familiar faces plan', which held crucial information, due to data limitations on their electronic devices. The coroner is concerned this vital information is not easily accessible to first responders in emergency situations.
Response (North East Ambulance Service): • North East Ambulance Service (NEAS) has instructed ambulance dispatch teams to verbally notify staff of any 'flags' and seek acknowledgement. • The character limit on Mobile Data Terminals (MDT) … (AI summary)
Responded
Lee Armstrong
Concerns: The NHS Pathways system does not prompt for existing conditions, and information from 111 online is not shared with NWAS. Call handlers also lack access to patient medical records, which may lead to crucial medical history not being known during emergency calls.
Response (NHS England): • NHS England described the existing design of the NHS Pathways system, which is symptom-based and enquires about pre-existing conditions when they may alter assessment outcomes. • NHS England confirmed … (AI summary)
Response (Department of Health and Social Care): • The Department stated that NHS England has a process in place to map 999 call triage system outcomes against ambulance response time categories. • The Department noted that the … (AI summary)
Overdue
Caroline and Bernard Cleall
Concerns: LB Croydon Adult Social Care could not access NHS LIFE team assessment records, including documented risk assessments and telecare advice from hospital discharge, hindering proper review of clients' post-discharge needs.
Response (London Borough of Croydon): • The client record system has been updated so all assessments are completed within the main body of the system, rather than as attached documents. • Careline service procedures have … (AI summary)
Responded
John Charles Spencer
Concerns: The coroner noted that GP medical history summaries are not always accessible to out-of-hours GP surgeries due to incompatible computer systems, even with patient consent, hindering appropriate medical examinations.
Response (NHS England): • The practices involved in the case migrated from EMIS to TPP SystmOne, enabling GP Connect. • NHS England is working across the health system to support greater integration and … (AI summary)
Response (Holderness Health): • Holderness Health migrated its clinical IT system to TPP SystmOne on 13th May 2024. • The new system includes GP Connect, which enables limited access to patient medical summaries … (AI summary)
Response (CQC): • The CQC contacted the GP practice and Out of Hours provider to establish the circumstances of the case and the providers' intended actions. • The CQC incorporates scrutiny of … (AI summary)
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated it would highlight this case to its health informatics group to influence discussions with NHS England. • The Royal College of General … (AI summary)
Responded
Chloe Ellis
Concerns: The West Yorkshire Integrated Care Board has not commissioned the accessibility of NHS 111 online assessment outcomes for Emergency Department clinicians at Mid Yorkshire Teaching NHS Trust. This means crucial patient history, such as suspicion of pulmonary embolism, is not readily available to clinicians.
Response (West Yorkshire Integrated Care Board): • West Yorkshire Integrated Care Board (WYICB) is working with national and local partners to facilitate the integration of the Booking and Referral Standard (BaRS). • The implementation of BaRS … (AI summary)
Responded
Kwabena Amoateng
Concerns: A critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and storing such important documents consistently in clinical records.
Overdue
Amy Pugh
Concerns: Clinical staff at Avondale Unit were unable to access important mental health records from partner NHS institutions, which compromised the patient's assessment and subsequent management.
Response (NHS England): • NHS England stated it has provided funding to support the implementation of Electronic Patient Record systems across all NHS Trusts. • NHS England is working across the health system … (AI summary)
Responded
Jean Groves
Concerns: The coroner expressed concern that emergency responders lack access details for vulnerable patients when assisting the ambulance service via the NHS "Access to the Stack" initiative, which could lead to future deaths.
Response (Norfolk County Council): • The manager involved committed to adhering to the correct procedure for recording declined referrals. • A communication will be issued to operational managers and reablement liaison officers, reminding them … (AI summary)
Response (Careline365): • Careline365 confirmed its procedures for recording and communicating property access information where it is provided. • Careline365 reviewed its onboarding and data capture processes to ensure appropriate prompts exist … (AI summary)
Responded
Akhona Moyo
Concerns: Hospital doctors at Northampton General Hospital lack electronic access to detailed primary care medical notes, including GP and community mental health records. This absence of crucial information hinders their ability to provide comprehensive patient treatment and care, particularly for vulnerable patients.
Response (University Hospitals of Northamptonshire NHS Group): • The Northamptonshire Care Record (NCR) and GP Connect are now available at NGH, providing clinicians with access to GP data including medications, allergies, and diagnoses. • Single sign-on integration … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care and NHS England have programmes of work underway to provide health and care professionals with access to a single source of digital … (AI summary)
Overdue
Select committee recommendations(15)
#10 —
Recommendation: The move to using social media for mass communications was partially successful. However, accessing online information was particularly difficult for elderly people and those with certain disabilities. The FCO placed too much reliance on this generic advice and this approach …
Response attribution not verified
#20 —
Recommendation: NHS health and publicly funded social care services are legally required, by the Accessible Information Standard, published under section 250 of the Health and Social Care Act 2012, to provide health and care information to patients and service users in …
Response attribution not verified
#15 —
Recommendation: We heard that more needs to be done to improve the way a disabled person’s communication preferences are recorded by Jobcentre Plus. DWP should take inspiration from the Accessible Information Standard model used in the NHS and create an automated …
Response attribution not verified
#19 —
Recommendation: The accessibility of the Government’s communications to disabled people during the pandemic has been poor from the outset of lockdown in March. The Government has been far too slow to address concerns, notably about the lack of British Sign Language …
Response attribution not verified
#9 —
Recommendation: A single information hub that delivers tailored information to young disabled people and their parents or carers would help them navigate the transition from education to work, identify appropriate support, and understand their specific rights and entitlements.
Response attribution not verified
#21 —
Recommendation: We agree with organisations representing Deaf British Sign Language users that we should set a good example in the accessibility of our public oral evidence sessions. It is regrettable that we did not provide live BSL interpretation and subtitles via …
Response attribution not verified
#14 —
Recommendation: It is unacceptable that some disabled people still face barriers when trying to access services through Jobcentre Plus. It is particularly shocking that services provided by the Department for Work and Pensions, whose ministerial team includes the Minister for Disabled …
Response attribution not verified
#11 —
Recommendation: Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.
Response attribution not verified
#16 —
Recommendation: The Department told us that the use of remote hearings is at the discretion of the judge in each individual case, and that everybody is entitled to have their reasonable adjustments considered by the judge. However, a third of people …
Response attribution not verified
#15 —
Recommendation: Since the start of the pandemic, the Department and HMCTS have significantly increased the use of hearings held remotely using video technology, and plan to continue to use them to reduce the backlog in the courts.25 We asked what impact …
Response attribution not verified
#5 —
Recommendation: Vulnerable users and people from ethnic minority backgrounds are potentially impacted disproportionately by efforts to tackle the Crown Court backlog, which the Department and HMCTS have not done enough to understand. Since the start of the pandemic, HMCTS significantly increased …
Response attribution not verified
#16 —
Recommendation: Additionally, Mencap raised concerns with us about specific difficulties in identifying and prioritising people with severe and profound learning disabilities.38 It said there was a need for more accessible communications for this group and to tackle needle phobia, which had …
Response attribution not verified
#10 —
Recommendation: The widespread adoption of continuous facemask wearing in health and social care settings has made effective communication impossible for patients and healthcare professionals who lip-read, and much more difficult for Deaf people who use British Sign Language and people with …
Response attribution not verified
#10 — Streamlined asylum questionnaires poorly designed, lack clear instructions, and are only available in English.
Recommendation: However the UNHCR, as well as the Public Law Project and Dr Jo Wilding from the Migration Law Clinic, have raised concerns about the streamlined asylum process questionnaire.23 Though the Home Office told us that it had worked with the …
Response attribution not verified
#3 — Require Ofcom to use internet access data for assessing linear content accessibility.
Recommendation: Allowing Public Service Broadcasters to use a wider range of services to contribute towards their remit, including on-demand, should not come at the expense of linear broadcast audiences. It is imperative that broadcasters make their content as accessible as possible …
Response status not verified
HSSIB safety recommendations(10)
Potential under-recognised risk of harm from the use of propranolol
It may be beneficial for the format of TOXBASE guidance to be reviewed to consider whether guidance documents may be better presented to allow clinicians to quickly and more easily interpret key steps in the treatment of overdose. HSIB notes …
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
Paramedics would benefit from the ability to access TOXBASE when responding to emergency calls.
Safety Observation
Mental health: attempted suicide while under the care of community services
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area of Improvement
Medication not given: administration of time critical medication in the emergency department
How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?
Learning Prompt
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area of Improvement
Surgical care of NHS patients in independent hospitals
HSIB recommends that NHSX expands its work programme addressing the challenges associated with interoperability of information systems used in healthcare to include transfer of information between the NHS and independent sector in support of safe care delivery.
Safety Recommendation
Provision of care for children and young people when accessing specialist gender dysphoria services
It may be beneficial if further work considered the ability to allow for shared record systems and ways to appropriately share information between NHS and non-NHS services involved in the care of patients with gender identity concerns.
Safety Observation
Investigation report: Clinical investigation booking systems failures - written communications in community languages
It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
Safety Observation
Investigation report: Clinical investigation booking systems failures - written communications in community languages
HSIB recommends that NHS England develops and implements a standard for healthcare providers on supplying written appointment information in languages other than English. HSIB makes the following safety observations
Safety Recommendation
Management of chronic asthma in children aged 16 years and under
It may be beneficial if suspected or possible asthma diagnosis is communicated by secondary care services to children, families, and other care sectors, when asthma is being considered as a possibility (but not formally diagnosed).
Safety Observation
NCEPOD recommendations(4)
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
CQC inspection actions(20)
Pilgrim Hospital
The trust should ensure an interpreter is used as per trust policy to ensure all young people, parents or guardians are able to consent to care and treatment and fully understand clinical conversations.
Should Do
Pilgrim Hospital
The trust should ensure it has access to communication aids and leaflets available in other languages.
Should Do
Clatterbridge Hospital
The services should review the format and language availability of patient information offered.
Should Do
Chorley and South Ribble Hospital
The trust should ensure that all patients with protected characteristics are supported such as availability of information in formats that patients understand.
Should Do
St Benedict's Hospice
The trust should continue to explore ways to improve access to electronic systems with the local mental health trust.
Should Do
St Benedict's Hospice
The service must comply with Accessible Information Standards by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability/sensory loss.
Must Do
Durham Diagnostics and Treatment Centre
The service must comply with Accessible Information Standards by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability/sensory loss.
Must Do
Birmingham Children's Hospital
The trust should ensure that records are accessible to both emergency department staff and the mental health team.
Should Do
367 Thornaby Road
We recommend the provider consider current guidance on accessible information and take action to update their practice accordingly.
Should Do
North Manchester General Hospital
The trust should ensure staff complete patient passports to support patients with additional needs if they were to return to hospital.
Should Do
Mount Vernon Cancer Centre
The trust should ensure there are leaflets available in languages other than English.
Should Do
Mount Vernon Cancer Centre
The trust must ensure that all necessary staff have access to records and information systems to enable them to review patient details. This includes investigation results from other providers.
Must Do
Fairfield General Hospital
The trust should ensure they review the trauma pathway so that all information relating to the patient is conveyed to staff on the day surgery ward, so that they can assess the patient’s suitability for admission.
Should Do
Princes Medical Centre
Continue to explore ways of improving communication barriers and making information more accessible.
Should Do
Pilgrim Hospital
The trust should consider the use of a communication tool to support staff working with children who have additional needs.
Should Do
Doncaster Royal Infirmary
The trust should ensure it continues to complete the work needed to meet the requirements for the Accessible Information Standards.
Should Do
Rochdale Infirmary
The trust should ensure staff complete patient passports to support patients with additional needs if they were to return to hospital.
Should Do
Newark Hospital
The provider should review patient information to ensure is clearly displayed and readily available in wards areas in languages other than English.
Should Do
Meet The Baby
The provider must ensure that there is access to independent interpreters to assist women whose first language is not English or who may have a hearing impairment to ensure that a relative does not act as an interpreter where there …
Must Do
DMC Church View Practice
Review do not attempt cardiopulmonary resuscitation (DNACPR) forms to ensure they are accessible to all.
Should Do
PPO death in custody recommendations(1)
IOPC learning recommendations(4)
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police ensures arrangements are in place for all custody officers, staff and HCPs to receive information about detainees when their shift starts. This follows an investigation into the death of a man at a …
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) review relevant policies and/or procedures to ensure they make clear the need to set up a password with nursing staff when officers have transported a medical emergency to hospital. A password …
Recommendation - Hampshire Constabulary, September 2024
The IOPC recommends that Hampshire Constabulary creates and implements a memorandum of understanding (MOU) regarding sharing patient information with University Hospital Southampton NHS Foundation Trust. This follows an investigation in which a man was found by police in a hospital …
Recommendation - Metropolitan Police Service, February 2023
The IOPC recommends that the Metropolitan Police Service (MPS) explores the options, to include making an audio-recording, to ensure the Police and Criminal Evidence Act 1984 Codes of Practice are accessible in custody for detained persons with sight impairment. Any …
IMB individual recommendations(45)
Springhill (2022)
Ensure the delivery of health champions and the wellbeing hub, as well as improved access to healthcare data.
Governor / Director
Gartree (2023)
The following question is repeated from last year’s annual report: will the Prison Service work with the Board to ensure that it has access to necessary information, such as healthcare data, for example, so that the Board is able to monitor more effectively how well the prison is meeting the standards and requirements placed on it and what impact these …
HMPPS
Gartree (2023)
The Board has continued to struggle to obtain meaningful data about healthcare provision to enable monitoring of waiting lists and patients’ clinics, etc, so that we can ascertain whether or not they are being provided at a satisfactory level.
Ministry of Justice
Bedford (2023)
The lack of a suitable computer in the healthcare rooms in reception means that healthcare staff cannot access the personal escort records.
Governor / Director
London STHF (2024)
Delays and unavailability of certain languages in The Big Word translation service need to be addressed.
Other
Gatwick IRC (2024)
Ensure that suitable training and support is provided so that professional interpretation services are used effectively in communications with the detained men, particularly during critical safeguards such as initial screening, and Rule 34 and 35 appointments.
NHS / Healthcare Provider
Rejected
North East Midlands, Yorkshire & Humber STHF (2025)
In the light of delays in ambulance and paramedic attendance following an incident at Swinderby RSTHF, we recommend the use of ‘what3words’ or other precision location tools to aid navigation to places of detention and that lists of such places with the location details be readily available to paramedic crews. This is relevant not just for places such as Swinderby …
NHS / Healthcare Provider
Highpoint (2020)
In order for mental health practitioners to provide timely interventions, there is a requirement for prisoner records to be transferred between establishments when a prisoner is relocated. The Board asks for a co-ordinated and regulated procedure to be established to ensure this happens.
HMPPS
Implemented
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Home Office should arrange for Wi-Fi and internet access for detainees, even if it is only available when DCOs can supervise (para. 8.12 – 8.13; 12.13 – 12.15; 25.4; 33.4).
Home Office
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Home Office should speed up their introduction of electronic translation devices, which they have already trialled (para. 4.11; 8.4; 17.3).
Home Office
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Board repeats the request for dual handset phones so that Detainee Custody Officers (DCOs) and detainees can use the Big Word interpretation service more easily and with privacy (para. 4.10; 17.2).
Home Office
Oakwood (2022)
During the reporting year the Board has been concerned that the healthcare complaint boxes were not emptied on a regular basis and their location is not easily accessible to all prisoners at all times. The Board asks the Director to review this with the head of healthcare (see para 6.1).
Governor / Director
Gatwick IRC/RSTHF (2022)
Review the service offered by Big Word and consider alternatives where they will improve availability (section 5.5).
Home Office
Gatwick IRC/RSTHF (2022)
Strengthen the consideration given by caseowners to local knowledge (Home Office, Serco and PPG) about a detained man’s situation and condition, especially through the AAR mechanism, and review the thresholds applied to the balance between immigration factors and humanitarian considerations (section 4.4).
Home Office
Erlestoke (2022)
What is the solution to improve the IT infrastructure so medical records can be accessed across the estate to ensure prisoners are not put at risk?
NHS / Healthcare Provider
In Progress
Bedford (2022)
The digitising of the personal escort records has made it harder for healthcare staff to access them.
HMPPS
Erlestoke (2023)
What is the solution to improve the IT infrastructure so medical records can be accessed by healthcare staff across the estate to ensure prisoners are not put at risk?
Governor / Director
Dartmoor (2023)
What more can be done to ensure that Foreign National Prisoners, some of whom have little or no English, have access to notices and information provided in their own language(s)?
Governor / Director
Isle of Wight (2024)
Can appropriate equipment/instruction materials be immediately installed in the IHU so that translation services are available for prisoners located there and for prisoners who arrive outside of core hours when initial health screening takes place in the unit?
Governor / Director
Gatwick IRC (2024)
Establish suitable mechanisms with relevant other parties to ensure that information regarding men's medical conditions/medication, vulnerabilities or security risks arrives with them or is shared in a timely way.
Governor / Director
In Progress
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB would like to have reassurance that centre protocols are to be revised to ensure that explicit procedures are in place to enable healthcare professionals (both internal staff and external paramedics) to attend health emergency incidents as quickly as possible – including the allocation of fast escort staff to facilitate this and the use of locational tools such as …
Other
Portland (2020)
The number of prisoners failing to attend for pre-arranged healthcare appointments because operational support grade (OSG) staff have not followed agreed protocols is not acceptable. This is the second year running that this situation has ensued.
Governor / Director
Foston Hall (2020)
The lack of suitable interview rooms across the prison, to facilitate welfare and rehabilitative work with prisoners (see paragraphs 5.5.6, 6.1.10 and 7.5.2).
Governor / Director
In Progress
Foston Hall (2020)
There is a lack of suitable interview rooms across the prison, for use by healthcare staff, psychologists, chaplains and other service providers, which significantly undermines the delivery of positive rehabilitative work (see paragraphs 5.5.6, 6.1.10 and 7.5.2).
HMPPS
In Progress
Erlestoke (2020)
Communication between Prison Reception Staff and Healthcare Reception Staff is unsatisfactory (see paragraph 8.7). Will this problem be addressed?
Governor / Director
Parc (2021)
There were issues surrounding the ability of healthcare staff to provide an appropriate service to prisoners as a consequence of there being insufficient telephones available. Any issue of this nature should be treated as an absolute priority.
Governor / Director
Huntercombe (2021)
To develop a process with healthcare to ensure there is documented sharing of appropriate health information with prison staff (paragraph 6.1.8.).
Governor / Director
Erlestoke (2021)
Will further efforts be made to ensure that firstly, prison staff liaise with healthcare staff to inform them of forthcoming reviews and secondly that better arrangements are made to schedule reviews for healthcare operating hours?
Governor / Director
Oakwood (2022)
A further concern for the Board is the fact that the letter sent to explain how a request will be dealt with is long and not always clear for prisoners who cannot read easily or whose first language is not English. These multi-functional response letters are not dated and do not have any reference numbers assigned for easy identification in …
Governor / Director
London Heathrow and City Airports (2022)
[All holding rooms] The Board recommends that Wi-Fi is accessible in the holding rooms for those with hearing and speech impairment, so that they can communicate with DCOs. (See paragraphs 4.3.35 – 4.3.37)
Home Office
Thameside (2023)
Please can those in HMPPS with responsibility for contracted out prisons ensure that all IMBs in those prisons have access to the same resources as our colleagues in the public sector, as there is much discrepancy and full access to NOMIS has been an issue for a number of years and is still not fully resolved.
HMPPS
In Progress
Kent Coast Short Term Holding Facilities (STHF) (2023)
Have visual information on the screens and for interviewing instead of just written format.
Home Office
London STHF (2024)
We repeat the recommendation that the detention contractor should ensure that DCOs use The Big Word interpretation service for inducting non-English-speaking passengers and that they should not assume that passengers with a limited grasp of English really understand what they are being told.
Other
Kent Coast Short Term Holding Facilities (STHF) (2024)
The Board recommends that there should be visual information on the screens instead of it just being in a written format. In addition, detained people should have access to visual aids to help them when they are being interviewed.
Home Office
Partially Accepted
Berwyn (2024)
The Board recommends putting in place measures to radically improve the take up of internal medical appointments.
Governor / Director
Five Wells (2025)
What steps are being taken to introduce electronic communication between the healthcare unit and prisoners?
Governor / Director
Five Wells (2025)
What steps are being taken to introduce electronic communication between the healthcare unit and prisoners?
Governor / Director
Chelmsford (2025)
Launchpad has been a great success in allowing prisoners to check and verify personal information. Will the Prison Service commit to adding a feature so prisoners can book and manage their medical appointments? If so, what timeline do you anticipate for implementation?
HMPPS
Gatwick, Stansted, Luton and Lunar House (2020)
We do not believe that the arrangements for the monitoring of the medical welfare of detained individuals within the holding rooms are adequate and in particular there is potential risk to the health of an individual who needs urgent access to their medication or medical equipment.
Home Office
Swaleside (2021)
The continued occupancy of the life limited room in Healthcare by one paraplegic resident whose needs are different, whilst there are a number of other residents who qualify for the use of this room. (see sections 3.1 and 6.1)
HMPPS
In Progress
Stafford (2021)
Will HMPPS provide direction to the population management unit (PMU) that they must take more responsibility regarding the suitability of residents they transfer to HMP Stafford (e.g. residents who cannot manage stairs yet the sending prison has categorised them as fit and well)? Inappropriate transfer of the kind seen during the period of this report places unfair pressure on prison …
HMPPS
Rejected
Isle of Wight (2023)
How will the Governor ensure translated induction material is always available and remove possible barriers to the use of translation services. This should include providing speaker telephones and training for health workers who cover reception health screening outside of core hours from the IHU.
Governor / Director
Bedford (2024)
We are concerned about the large rise in applications we have received about healthcare, the general negative view of prisoners and the lack of access to healthcare managers.
Governor / Director
London short term holding facilities (STHF) (2025)
The Board would like the lack of signal in Terminal 2 to be urgently addressed, so that a translation device can be used to communicate with detained people.
Ministry of Justice
Belmarsh (2025)
Will the Prison Service look at ways of providing a technological solution, such as computer tablets, to assist in translations for foreign national prisoners with limited English, particularly in a healthcare setting?
HMPPS
In Progress
Health investigations(91)
*Mental health homicide investigation legacy report into the care and … — Rec L4
The trust should continue to develop relationships with partnership agencies. This should include reviewing the protocols with partnership agencies to ensure effective communication and information sharing for the safety of patients and the general public e.g. information to service providers such as housing associations and hostels. This should take place …
south_east
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 3
The importance of ensuring clarity and accuracy of recording and dissemination of information is an essential part of inter-agency working. The panel were concerned at the effectiveness of the system of exchange of information between Mental Health Services and the accommodation provider - New Horizons (Teesside). The inquiry therefore recommends …
north_east_yorkshire
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 19
We recommend that when police are involved in an admission because of a patient’s aggression or violence, all relevant details should be obtained from the police, by the hospital, including previous instances of aggression or violence. Such action should also form part of the risk assessment process when a patient …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 13
We recommend that nursing staff who receive a patient into their care from the police or ambulance staff should exchange contact information with those staff. Nurses should record this information, together with the time of transfer, on the patient’s file. We believe this to be important in terms of the …
northern_ireland
Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006) — Rec 4
Inter-Agency Risk Management Arrangements should be reviewed and changes made to ensure that: a. There is appropriate representation of agencies at meetings (such as MARAC and MAPPA) to ensure that information from those who have direct knowledge of the patient/service user is available when cases are being discussed. b. All …
wales
Independent investigation: Rina Panchal, Thurmaston, Leicester (2007) — Rec 4
For Leicester City Council’s Children and Young People’s Services (CYPS) need to consider producing a guidance note on core information it requires from other agencies in preparation for reports where professionals cannot attend for multi-agency meetings. The IIT understands that CYPS is of the view that, when professionals and agencies …
midlands
Independent investigation: Richard Price, Bromley (2009) — Rec 1.9.6
The CFT should always try to get background information about a patient through other agencies such as Probation, MAPPA, previous providers of psychiatric services etc, so as to get as full a picture as possible of the patient and the risks they present.
london
Independent investigation: Maxine Penfold, Cullompton, Devon (2004) — Rec 1.4
Irrespective of how multi-disciplinary (and multi-agency) teams are structured and located, mechanisms are in place to ensure that all practitioners can utilise the above system.
south_west
Independent investigation: Matthew Carter, Tooting (2006) — Rec R18
The EIS should review its practice and procedure about informing local authority housing departments and carers under their supported housing schemes of the risk histories and risk assessments of service users and of significant revisions to the CPAs of service users.
london
Independent investigation: Kenneth Auger, Merthyr Tydfil (2008) — Rec 3.2e
Review the arrangements currently in place for accessing patient records across their respective organisations with the aim of developing a single information sharing system across health and social services. In particular, work needs to be done urgently to ensure uniformity of access to electronic records across the whole of the …
wales
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 3
NHS London should share with other mental health and learning disability Trusts the risk that Consultant Forensic Psychiatrists visiting prisons may not input and update electronic patient record systems meaning that critical information is not shared with community mental health teams when patients are discharged from prison.
london
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.23
Young people “looked after”, in the transition phase, and receiving mental health care should have their needs reviewed jointly between agencies. This should include primary health care and education. The outcome should be a care plan available to all including the young person.
north_west
Independent investigation: Joanne Whitelegg, Bolton, Lancs (2000) — Rec 4.20
Social Services formal systems for circulating review or conference minutes should include the GP as the primary health care giver, as well as the community paediatric service and CAMHS, if involved.
north_west
Independent investigation: Jane WheatleyGary Gardiner, Sheffield (2007) — Rec 4
The Trust should develop robust methods of reviewing its information sharing policies (both internal and external) to assess their effectiveness and to implement changes as required. Reviews should include investigations of the timeliness of responses from other agencies.
north_east_yorkshire
Independent investigation: Jan Jensen, Hassocks (2012) — Rec R5
The trust should establish a process with the police, probation and prison services for rapidly obtaining information about forensic histories and index offences where patients are deemed a risk to others.
south_east
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 8
Sefton Safer Communities Partnership should ensure that all agencies involved in Multi-Agency Risk Assessment Conferences (MARAC) and Multi-Agency Public Protection Arrangements (MAPPA) consistently record detailed notes of discussions and agreed actions, particularly concerning individuals with mental health issues and a history of violence. Clear protocols should be established for sharing …
north_west
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 4
NHS England should ensure that all mental health professionals working in Accident and Emergency departments and crisis teams have access to comprehensive patient records, including those held on SystmOne by prison healthcare providers, to enable informed decision-making during mental health assessments. Where direct access is not immediately feasible, clear and …
north_west
Independent investigation: Bernadette FoxSarah Fox, Bootle (2015) — Rec 2
Sefton Safer Communities Partnership should review and update its multi-agency information sharing protocols to ensure that all relevant information, particularly concerning individuals with complex needs (such as mental health issues and a history of offending), is effectively shared between agencies, including prison mental health services, community mental health teams, probation, …
north_west
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.3
With regards to HMP Parc and consent issues being a potential barrier to making a referral to health and social care agencies, HIW believes that a clear protocol should be put in place whereby consent can be overridden when appropriate. This should also be made clear on the consent forms …
wales
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.2
Processes for ensuring that all agencies and individuals involved in the care, treatment and support of an individual who absconds should be kept up to date. All agencies should ensure that they are informed of an individual’s arrest and the prison to which they are returned to.
wales
Independent investigation: Anthony Kitely, Cardiff (2009) — Rec 3.15
Cardiff and Vale Health Board should review the arrangements that it has in place for sharing information across its mental health teams and services and with other agencies.
wales
William Mead – Root Cause Analysis Investigation Report — Rec d)
That NHS England South escalates the importance of progressing the information / record-sharing agenda for all NHS bodies.
south_west
William Mead – Root Cause Analysis Investigation Report — Rec a)
That NHS England identifies existing initiatives such as Care Connect in the SW that will enhance the sharing of patient records and information, and subsequently produces a programme of development for the SW.
south_west
*Independent investigation into the care of Mr A: March 2013 — Rec 4
CPFT and the MHIRT should undertake a review of the pathways through which information concerning offenders is received, requested and recorded in order to ensure that information concerning the needs of individual offenders and the risk that they pose is available to all members of the MHIRT.
Cambridge and Peterborough NHS Foundation Trust
east_of_england
*Independent investigation into the care and treatment of Patient 2009/3245: … — Rec 5
Current strategies should be reviewed within inter-agency working (inclusive of non-statutory agencies), to ensure practitioners and those delivering care understand the significance of risk assessment, risk management and the established relationship between historical risk and current risk. The sharing of formal risk assessment information should be considered.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
*Independent investigation into the care and treatment of Patient 2009/3245: … — Rec 3
The importance of ensuring clarity and accuracy of recording and dissemination of information is an essential part of inter-agency working. The panel were concerned at the effectiveness of the system of exchange of information between Mental Health Services and the accommodation provider - New Horizons (Teesside). The inquiry therefore recommends …
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
Independent investigation into the care and treatment of Mr T … — Rec R5
Senior trust managers should negotiate with senior managers from partner agencies the level of information sharing at Multi Agency Public Protection Arrangement (MAPPA) meetings to ensure it is consistent with national good practice.
Mr T and Mr U . At the time of the homicide (2012) Mr T and Mr U were ex-mental health service-users from Berkshire Healthcare NHS Foundation Trust
south_east
An independent review of the Level 2 RCA investigation into … — Rec 3
The Trust and CCG need to ensure that all sources of evidence (i.e. clinical care records, General Practitioners and the police) have been checked when investigators report an absence of family members for perpetrators and/or victims of serious incidents or homicides.
south_east
An independent review of the care and treatment received by … — Rec R5
Information sharing and communication are essential components in providing safe and effective care for patients. The trust should assure themselves that there are robust systems in place on the acute admission ward to ensure that all relevant staff are provided with important information in a timely manner. This should include …
north_east_yorkshire
An independent mental health homicide investigation into the care and … — Rec 7
AWP should consider the feasibility of allowing Cygnet Health Care’s inpatient unit to have access to a patient’s AWP records.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent mental health homicide investigation into the care and … — Rec 6
AWP should establish an information sharing protocol between all agencies involved in the provision of services within Bristol Mental Health
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent investigation into the care and treatment provided to … — Rec 5
Information sharing protocols need to be built into the new Adult Care Pathway. This will be a complex task but will be essential in order to underpin new ways of working in the best interests of service users.
Mr X, Ms Y and Mr Z NHS England has published the independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust
south_west
An independent investigation into the care and treatment provided to … — Rec 3b
The Trust and its partners from the police, MAPPA and probation services should consider the findings and conclusions of this Independent Investigation and route Mr X and Ms Y as case studies through current processes to ensure that service users with a similar profile would not be ‘lost’ to service …
Mr X, Ms Y and Mr Z NHS England has published the independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust
south_west
An independent investigation into the care and treatment of Mr … — Rec 15
In order to evaluate the effectiveness of the new information-sharing systems introduced since this incident, the Trust should consider undertaking an audit exercise of a number of cases, involving similar complex patients, where there is both internal and external multi-agency involvement.
Mr S . At the time of the homicide, he was receiving services from Somerset Partnership NHS Foundation Trust
south_west
An independent investigation into the care and treatment of a … — Rec R4
Full forensic history from [Police National Computer] PNC if agencies such as probation are involved.
south_west
Accepted
An independent investigation into the care and treatment of a … — Rec R2
All professional letters to be [copied] into whoever is identified as working with the person e.g. Harbour, Probation.
south_west
Accepted
An assessment of a mental health trust’s internal investigation of … — Rec R6
A system-wide information sharing agreement or memorandum of understanding to be put in place, so that all agencies involved in the care, treatment or management of a service user are given the opportunity to contribute to a system wide investigation, and investigators have access to all relevant records.
north_east_yorkshire
An assessment of a mental health trust’s internal investigation of … — Rec R5
The trust should ensure robust application of existing mechanisms for sharing relevant information with known system partners. The cross-agency sharing of information about service users with severe mental health conditions, particularly when combined with drug dependency and a history of violent and criminal behaviour, can lead to better management of …
north_east_yorkshire
Investigation Report into the NHS Care provided to the late … — Rec 6.4
The urgent care system as a whole should explore ways to ensure that when patients present to different organisations, information is more effectively shared.
south_east
Investigation Report into the NHS Care provided to the late … — Rec 6.3
The interface between NHS 111 and Trust 5 should be improved to ensure that clinical information is more effectively shared between the two organisations.
south_east
Independent Quality Assurance Review – Norfolk and Suffolk NHS Foundation … — Rec 1
The Trust should utilise the joint information sharing agreement with Suffolk Constabulary to clarify patients’ forensic history, within the bounds of the accepted criteria.
Norfolk and Suffolk NHS Foundation Trust
east_of_england
Independent investigation of the care and treatment of Mr N — Rec 1
Within three months. The young people’s community service CR&HTT Standard Operating Procedures should be updated to include a clear requirement to make every attempt to contact all relevant agencies, including police & probation if applicable, for additional information to inform care plans and risk assessments. Actions to take if information …
midlands
Independent investigation into the care and treatment of Patient R: … — Rec 6
The Trust should consider whether, when a service user is known to have a particularly peripatetic lifestyle and there are significant concerns about risk, contact should be made with appropriate mental health trusts to share information (with due regard to guidance on confidentiality).
5 Boroughs Partnership NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of Ms A: … — Rec 7
A review should be undertaken of the current Multi-Agency Information Sharing Protocol that is in place within Tees, Esk and Wear Valleys NHS Foundation Trust’s area to ensure that all services are operating within the protocol.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr S — Rec 6
The Trust must work with partner agencies providing accident and emergency services to ensure that the joint operational policies are complied with, in particular that clinical records are available to psychiatric liaison staff in a timely fashion, to facilitate fully informed assessment of patients.
Mr S who committed a homicide in November 2012. Mr S had previously received treatment from Central and North West London NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr P: … — Rec 2
Lancashire Care NHS Foundation Trust and Mersey Care NHS Trust should review the effectiveness of their systems for receiving information about prisoners from external agencies and entering it into the health care record. The aim should be to ensure that information from other agencies, while subject to the required protection, …
5 Boroughs Partnership NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Mr I — Rec 8
Providers of substance misuse services should identify and agree a system of sharing risk information about clients who move between service providers, whilst adhering to patient confidentiality.
Mr I who committed a homicide in April 2012. At the time of the death, Mr I was in receipt of mental health service from Central and North West London NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr F: … — Rec 8
NHS England’s Regional Homicide Leads need to address the lack of information sharing by prisons’ medical services.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr F: … — Rec 6
Secondary mental health care services should be aware that patients on a methadone programme in this area may be registered with two primary care services. If this is the case, they must ensure that communication is being sent to both services.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr F: … — Rec 5
When a patient is registered with two primary health care services, there needs to be improved communication and information sharing between the practices.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
Michael Towell
The Sheriff Principal, having considered the information presented at the inquiry, in terms of 26(1)(b) of the Act, recommends: R1. That the BBBC should, as soon as reasonably practicable, obtain from each boxer presently licensed by them details of their current GP and of any other medical professional from whom they have received treatment in the past 12 months; R2. …
Apr 2019
Xi Biao Huang
(i) All medical assessments, and particularly clinical examinations should be carried out with the use of a professional interpreter where the detainee does not speak fluent English. Whilst the nature of the establishment may mean that it would not be possible or practicable to use professional interpretation services for every interaction with a detainee, the use of fellow detainees and/or …
Apr 2023
Custody
14 recs
Independent reviews(12)
Harris Review: Deaths in Custody — Rec 85
The Secretary of State for Justice should introduce legislation to create a statutory duty of cooperation for the sharing of information with the Prison Service to be placed upon those organisations that have direct engagement with the Prison Service (including health, mental health services, police, etc.). Primary Recommendations
Justice & Legal
Harris Review: Deaths in Custody — Rec 82
Guidance from health organisations should be considered to reflect the duties of the State to protect life in custodial settings, with appropriate guidance given as to the disclosure and sharing of health information in such settings (including in those instances where consent is not provided).
Justice & Legal
Harris Review: Deaths in Custody — Rec 79
Department of Health, Home Office and the Ministry of Justice need to issue joint guidance to the effect that when consent to sharing medical information has been given by a person in custody, then the assumption is that that consent remains valid (unless withdrawn) throughout the criminal justice journey of …
Justice & Legal
Harris Review: Deaths in Custody — Rec 78
Any health assessment (both physical and mental) produced at the police station by the liaison and diversion practitioner and others at the start of a prisoner’s journey through the criminal justice system should be shared amongst specified CJS organisations (e.g. CPS, legal team, NOMS, HMPS) in order to assist them …
Justice & Legal
Harris Review: Deaths in Custody — Rec 74
When the transfer is between the youth estate and an adult institution, the YJB will be accountable for the transfer of all relevant information from the YOT, including health, mental health and care leaver status.
Justice & Legal
Harris Review: Deaths in Custody — Rec 68
There should be a consistent approach throughout the criminal justice system to requesting consent to share medical information, which should happen at the first point of contact with the health services in a CJS setting, whether that be at a police station or at a prison, and that that consent …
Justice & Legal
Harris Review: Deaths in Custody — Rec 80
An appropriate consent form should be available which reflects the above, and in particular requesting of such consent should be a standard part of any prison reception assessment.
Justice & Legal
Tickell Review of the EYFS — Rec 14
I recommend that an insert is added to the early childhood health record, known as the Red Book, to encourage parents and carers, or their nominee, to enter information arising from this early years summary and from children's interaction with other professionals, for example speech and language therapists.
Education
Selous Review — Rec 38
The Department for Education and the Ministry of Defence to work closely with the Devolved Governments through MODLAP to ensure EHCPs, SCANs and other similar records are fully transportable and transferrable, and ensure that they include information from previous schools, including those overseas.
Other
Taylor Youth Justice Review — Rec 16
The police, CPS, local authorities and health services should establish local protocols in order that all charging decisions take account of health screening assessments conducted in police custody or as a result of the offence, and any relevant information on the child that the local authority holds. (Paragraph 74)
Justice & Legal
Neurodivergence Task and Finish Group: report — Rec 3
Recommendation Three: Develop clear partnerships for supporting neurodivergent needs between education, health, and social care DfE and DHSC must act at pace to co-ordinate activity for improving service integration. Health, social care and education should be better integrated with clear local partnership arrangements. Educational Psychology services should be enabled to …
Health & Social Care
Selous Review — Rec 39
The Department for Education to: • strengthen the SEND Code of Practice to ensure local authorities make full use of assessments made by MOD professional disciplines as part of the MOD SCAN (Service Child Assessment of Need) documentation • require local authorities to use assessment of needs contained within MOD …
Other
PHSO casework decisions(12)
P-004381 — Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board
Ms P complained the ICB failed to commission a British Sign Language (BSL) service with qualified deafblind interpreters, causing her anxiety, distress, and financial burden from private interpreter costs.
NHS in England
Dec 2025
P-001862 — Health Assessment Advisory Service
Mr U complained the Health Assessment Advisory Service refused his request for a home/paper-based assessment and failed to consider supporting evidence about his medical conditions.
UK Government
Mar 2023
P-002035 — Barts Health NHS Trust
Miss W complained about the Trust's care for her deaf sister during brain surgery, citing no care plan, lack of BSL interpreter, poor communication, and failure to investigate a lump.
NHS in England
Jun 2023
P-003043 — Birmingham Community Healthcare NHS Foundation Trust
Mrs E complained the Trust held meetings and made epilepsy treatment decisions for her son without her presence or seeing him, leading to potential misdiagnosis and medication side effects.
NHS in England
Oct 2024
P-003798 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complained staff did not listen to her father's unwellness and the Trust failed to provide regular BSL interpreters, instead using her children. She also questioned the complaint meeting interpreter and response.
NHS in England
Partly Upheld
Mar 2025
P-003810 — An independent provider in the Gloucester area
Mr E complained the Practice denied him reasonable adjustments for evening appointments and the ICB failed to secure GP access for him. He also alleged improper complaint handling.
NHS in England
Aug 2025
P-004462 — A practice in the Lincoln area
Mr H complained the Surgery failed to provide reasonable adjustments for booking appointments, leading to delayed healthcare access, worsening health, and significant distress.
NHS in England
Upheld
Nov 2025
P-001745 — Royal Berkshire NHS Foundation Trust
Mrs Z complained the Trust treated her unfairly due to a child protection plan and delayed investigations for her autistic daughter due to a lack of reasonable adjustments.
NHS in England
Jan 2023
P-002796 — Hull University Teaching Hospitals NHS Trust
Mr R complained the Trust ignored his LPA status, failed to communicate with him, did not implement a DoLS for his mother, and discharged her without informing the family.
NHS in England
Jul 2024
P-003038 — Mid and South Essex NHS Foundation Trust
Trust did not appropriately assess Miss T's symptoms or call her MS nurse during ED visits, delaying infection diagnosis and treatment, which she claims almost caused her death.
NHS in England
Oct 2024
P-002413 — North West Anglia NHS Foundation Trust
Miss I complained North West Anglia NHS Foundation Trust staff were unprofessional regarding her communication needs and failed to follow disability policies for deaf people.
NHS in England
Jan 2024
P-002368 — NHS England
Mr E complained NHS England's special care dental service guidance does not comply with the Equality Act 2010, making it difficult for autistic people to access dental care.
NHS in England
Dec 2023
LGO / SPSO decisions(65)
21-003-521 — Sefton Metropolitan Borough Council
Summary: Mr X complained about the Council’s decision not to provide him with a Blue Badge. He says the Council did not properly consider his application and this caused him avoidable distress and inconvenience. We found fault regarding the Council’s communications with Mr X. The Council has agreed to reconsider …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-004-654 — Royal Borough of Greenwich
Summary: The Council was at fault for the way it dealt with Mr X’s housing application. The Council delayed in referring Mr X to an Occupational Therapist, delayed in reviewing Mr X’s medical priority and request for an additional bedroom and was at fault for the way it reached its …
LGO (Local Government & …
Housing
Upheld
Feb 2022
21-006-708 — Nottinghamshire County Council
Summary: Mr B was unable to make an online application for a Blue Badge because of his disability. There was fault in the Council’s failure to offer an alternative way to apply for Mr B. The Council has already remedied this fault as it offered a telephone application to Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-015-223 — London Borough of Croydon
Summary: The Council failed to properly consider Mrs X’s application for a blue badge because it failed to record the reasoning for its decisions and failed to undertake a mobility assessment.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2022
23-014-778a — Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in …
LGO (Local Government & …
Health
Upheld
Sep 2024
NIPSO-202002242 — Education Authority
NIPSO (NI Public Service…
Education
Nov 2022
21-006-479 — London Borough of Southwark
Summary: Mr R complained about the way the Council dealt with his application to its housing. The Council made him a direct offer of unsuitable accommodation. And it did not consider medical evidence he submitted. The Ombudsman upholds the complaint about a delay in considering Mr R’s medical evidence. But …
LGO (Local Government & …
Housing
Upheld
Jul 2022
23-011-152a — Calderdale & Huddersfield NHS Foundation Trust (23 011 …
Summary: Ms D complains about faults by Calderdale Metropolitan Borough Council and Calderdale & Huddersfield NHS Foundation Trust in managing her mother, Mrs X’s, discharge from hospital. We have upheld Ms D’s complaints about assessing Mrs X’s ability to make her own decisions, consent and sharing information about community nursing …
LGO (Local Government & …
Health
Upheld
Aug 2024
23-018-381 — London Borough of Lewisham
Summary: Ms Q complained about the Council’s handling of her housing application and assessment of medical priority. She said she experienced distress due to the impact her housing circumstances had on her. We found the Council at fault for causing significant delays in her 2022 request for medical priority, but …
LGO (Local Government & …
Housing
Upheld
Aug 2024
23-019-136 — London Borough of Lewisham
Summary: Miss B complained about the way the Council considered her medical needs in connection with her housing application. We have found some fault in the way the Council communicated its decisions to Miss B. But we consider the Council’s most recent review properly explained the decision. The Council has …
LGO (Local Government & …
Housing
Upheld
Aug 2024
25-007-329 — Cambridge City Council
Summary: We will not investigate this complaint about the Council’s management of Mr X’s council tax account nor its failure to make its telephone line more accessible for disabled users. This is because an investigation would not lead to a different outcome for Mr X.
LGO (Local Government & …
Benefits And Tax
Oct 2025
25-009-696 — London Borough of Waltham Forest
Summary: We will not investigate this complaint about the Council’s failure to consider medical evidence when assessing the suitability of Miss X’s temporary accommodation. This is because the Council has agreed to a suitable remedy.
LGO (Local Government & …
Housing
Upheld
Dec 2025
25-004-529 — Westminster City Council
Summary: We will not investigate this complaint about the Council’s failure to consider Mr X’s medical conditions when he applied for a change in banding on medical grounds. This is because the matters complained about are currently being raised in court.
LGO (Local Government & …
Housing
Dec 2025
21-005-008 — Kent County Council
Mr C complained the Council failed to consider all his medical information before refusing his Blue Badge application.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
21-007-457 — Kent County Council
Summary: Mr X complained about the Council’s refusal to issue a blue parking badge to him. He said that, as a result, it is more difficult for him to access the community and he undertakes fewer journeys. We found there was no fault with regards to the Council’s actions.
LGO (Local Government & …
Adult Care Services
Not Upheld
Feb 2022
21-015-284 — London Borough of Richmond upon Thames
Summary: We will not investigate this complaint about equipment a council occupational therapist placed in the complainant’s parents’ home. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. It is not unreasonable to expect the complainant to …
LGO (Local Government & …
Adult Care Services
Feb 2022
21-010-362 — Cornwall Council
Summary: Mr B complains the Council has not properly assessed his eligibility for a Blue Badge. The Council considered the evidence Mr B provided but it told Mr B that he could not provide information from his GP and this was fault. The Council has agreed to apologise to Mr …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-001-564 — London Borough of Haringey
Summary: Ms B complained about the delay in dealing with her complaint about children’s services. We found the Council delayed in completing the process and has not yet sent Ms B the reports in an accessible format. We have asked the Council to pay her £150 and send her the …
LGO (Local Government & …
Children S Care Services
Upheld
May 2022
21-014-849 — North Northamptonshire Council
Summary: The Council is not at fault for not allowing Miss X to bid on non adapted properties. It is at fault for removing Miss X’s priority for a level access shower when she asked for a bath with bath chair to be included with her housing application and for …
LGO (Local Government & …
Housing
Upheld
May 2022
22-002-137a — Manchester University NHS Foundation Trust (22 002 137a)
Summary: The Ombudsmen cannot investigate Mrs P’s complaint about a meeting to review her son L’s Education Health and Care Plan. This is because we cannot investigate complaints about what happens in schools and any actions of the Council that are inseparable from these events. We have decided not to …
LGO (Local Government & …
Health
Sep 2022
22-002-137 — Manchester City Council
Summary: The Ombudsmen cannot investigate Mrs P’s complaint about a meeting to review her son L’s Education Health and Care Plan. This is because we cannot investigate complaints about what happens in schools and any actions of the Council that are inseparable from these events. We have decided not to …
LGO (Local Government & …
Education
Sep 2022
22-000-794 — London Borough of Lambeth
Summary: There was fault in the Council’s actions. The Council has not carried out a mental capacity assessment of Mr C and has not considered alternative accommodation for him in his care plan. There were delays in the provision of suitable transport for Mr C to go to college. The …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-018-660 — Kent County Council
Summary: We will not investigate this complaint about the Council’s decision not to issue a Blue Badge to a group that provides transport for disabled people. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Apr 2024
23-020-919 — London Borough of Newham
Summary: We will not investigate this complaint about the Council failing to address Mr X’s need for a virtual court hearing due to his disability. The Council has upheld Mr X’s complaint and withdrawn the court action. We could not add anything more by investigating.
LGO (Local Government & …
Benefits And Tax
Upheld
May 2024
24-001-044 — Devon County Council
Summary: We will not investigate this complaint about an unsuccessful application for a Blue Badge. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
May 2024
23-020-881a — Gloucestershire Health and Care NHS Foundation Trust (23 …
Summary: We will not investigate a complaint about how a Trust and a Council dealt with a complaint about the care provided to the complainant’s brother. This is because he did not provide consent to share his information and this was appropriately considered by the organisations during the local complaints …
LGO (Local Government & …
Health
Jul 2024
23-020-881 — Gloucestershire County Council
Summary: We will not investigate a complaint about how a Trust and a Council dealt with a complaint about the care provided to the complainant’s brother. This is because he did not provide consent to share his information and this was appropriately considered by the organisations during the local complaints …
LGO (Local Government & …
Adult Care Services
Jul 2024
24-013-580 — London Borough of Lewisham
Summary: Mrs Y complains on behalf of her husband, Mr Y, that he has not been awarded a blue badge. Mrs Y says the Council failed to fully consider the evidence before making its decision. Mrs Y says this has caused stress and frustration and has isolated and affected Mr …
LGO (Local Government & …
Adult Care Services
Not Upheld
Apr 2025
24-017-995 — Folkestone & Hythe District Council
Summary: We will not investigate this complaint about the Council’s assessment of the complainant’s priority for housing which allegedly failed to consider her households medical needs. This is because the Council’s housing decision carried a right of review and it would be reasonable for her to have requested this and …
LGO (Local Government & …
Housing
Apr 2025
24-014-125 — London Borough of Tower Hamlets
Summary: Mr X complains the Council failed to properly consider the problems that arose in his assessment when he appealed its decision to refuse him a blue badge. We find fault with the Council’s response to his appeal and have agreed another assessment considering Mr X’s reasonable adjustments.
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2025
25-004-558 — London Borough of Hounslow
Summary: We will not investigate this complaint about an unsuccessful application for a blue badge. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Aug 2025
24-020-635 — Worcestershire County Council
Summary: Mrs B complained on behalf of her father, Mr C that the Council had failed to make reasonable adjustments to ensure Mr C could read and understand financial information about his care costs, despite knowing he had a visual impairment. We found fault in the Council’s actions which meant …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
25-006-475 — Cambridgeshire County Council
Summary: We will not investigate Mr X’s complaint about the Council’s decision to refuse him a Blue Badge. There is insufficient evidence of fault to warrant an investigation.
LGO (Local Government & …
Adult Care Services
Oct 2025
24-006-067 — London Borough of Newham
Summary: Ms C complains the Council has failed to renew her Blue Badge application. The Council is at fault for delay, and failing to provide proper reasons for rejecting Ms C’s review. This has caused Ms C uncertainty about whether the Council has properly considered her review request and her …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
201804596 — Edinburgh Health and Social Care Partnership
C complained to us about two matters relating to the partnership. Firstly, they were concerned about an occupational therapy assessment carried out to identify appropriate adaptations for a new property they were being offered, as they did not consider the adaptations made met their needs as a disabled person. Secondly, …
SPSO (Scottish Public Se…
Health and Social Care
Not Upheld
May 2021
25-000-692 — London Borough of Tower Hamlets
on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.
LGO (Local Government & …
Adult Care Services
Feb 2026
21-012-075 — London Borough of Islington
Summary: We will not investigate this complaint about the complainant’s application for a Blue Badge and a taxi card. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
Jan 2022
21-014-850 — London Borough of Ealing
Summary: We will not investigate this complaint about the Council’s decision not to award a Blue Badge. This is because the Council has offered to do a further assessment and it is unlikely we could add to the Council’s response.
LGO (Local Government & …
Adult Care Services
Feb 2022
22-000-060 — London Borough of Merton
Summary: We will not investigate this complaint about the Council’s decision not to award a blue badge for Mr X. There is not enough evidence of fault in the way the Council made its decision.
LGO (Local Government & …
Adult Care Services
May 2022
21-012-236 — Royal Borough of Greenwich
Summary: Mr X complained the Council decided not to replace the through lift in his property with a stairlift or sit-down lift. Mr X says the through-lift in place is not fit for purpose and is causing him distress and worry. The Ombudsman does not find fault with how the …
LGO (Local Government & …
Adult Care Services
Not Upheld
May 2022
21-011-626 — Gravesham Borough Council
Summary: The Council is at fault for failing to consider medical evidence Miss X provided in support of her housing application. The Council is also at fault for failing to consider any reasonable adjustments it could have made when corresponding with Miss X. We find this caused her distress and …
LGO (Local Government & …
Housing
Upheld
Aug 2022
23-018-219 — London Borough of Islington
Summary: We will not investigate this complaint about the Council’s decision to refuse a blue badge. There is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Adult Care Services
Mar 2024
23-013-485 — London Borough of Tower Hamlets
Summary: Mr X complained the Council refused to accept appropriate alternative documentation confirming the lease arrangements for his vehicle and declined his application for a residents parking permit. There is no evidence of fault in the way the Council considered Mr X’s application to transfer his parking permit.
LGO (Local Government & …
Transport And Highways
Not Upheld
Apr 2024
23-017-514 — London Borough of Tower Hamlets
Summary: There is no evidence the Council failed to take all relevant information into account when it decided not to award a Blue Badge.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2024
24-001-312 — London Borough of Newham
Summary: Miss X complained the Council failed to rehouse her to a larger property on medical grounds and failed to properly respond to her complaint. The Council was not at fault when it decided Miss X did not have a medical need for an extra bedroom. It accepted it was …
LGO (Local Government & …
Housing
Upheld
Oct 2024
24-008-433 — Essex County Council
Summary: We will not investigate Ms X’s complaint about the Council’s handling of her blue badge application. She says the Council delayed in processing her application. This is because the potential fault has not caused significant injustice.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-001-089 — Peterborough City Council
Summary: There was no fault in how the Council considered Mr B’s blue badge application. Although it disregarded some evidence, it has fully explained why it did so. In the absence of any fault in the Council’s decision-making, we have no power to question the decision itself.
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2024
24-023-017 — London Borough of Bromley
Summary: We will not investigate this complaint about how the Council dealt with an application for a Blue Badge. This is because there is insufficient evidence of fault.
LGO (Local Government & …
Adult Care Services
May 2025
24-020-966 — Rochdale Metropolitan Borough Council
Summary: We will not investigate Mrs X’s complaint about the Council’s decision to refuse her son Mr Y’s Blue Badge application and appeal, its consideration of his medical evidence, the basis of its decision-making, or the time the Council took to issue its decisions. There is not enough evidence of …
LGO (Local Government & …
Adult Care Services
May 2025
25-000-283 — East Sussex County Council
Summary: We will not investigate this complaint about the Council’s decision to refuse a Blue Badge because there is not enough evidence of fault.
LGO (Local Government & …
Adult Care Services
Jun 2025
Domestic Homicide Reviews(148)— showing 50 strongest matches
Oxford — recommendation 1
To have routine access to the list of LAC to enable the Trust to enter a flag on Trust hospital electronic patient records. This is being discussed with colleagues in children’s social care to ascertain the feasibility of sharing this information.
Oxford University Hospitals NHS Foundation Trust
Oxford University Hospitals NHS …
Oxford — recommendation 4
The Oxfordshire Safer Communities Partnership & Community Safety Partnerships and OSCB seek assurance that all agencies have in place systems for ensuring information regarding referral to MARAC is shared with all relevant frontline professionals.
Oxfordshire Safer Communities Partnership | Community …
Hillingdon — recommendation 4.6.5d
Hillingdon CCG to work with Hillingdon health service providers to ensure that all information systems enable the flagging of high risk victims of domestic abuse.
Hillingdon ICB
Hillingdon — recommendation 4.5.10
SHP to ensure that the new MASH arrangement addresses the information sharing needs of schools and education services about cases of domestic abuse.
Safer Hillingdon Partnership (SHP)
Hillingdon — recommendation 4.5.6
SHP to establish a task a finish group in order to develop a multiagency protocol on information management including creating a common information record and sharing information on victims and perpetrators of domestic violence.
Safer Hillingdon Partnership (SHP)
Hillingdon — recommendation 4.5.5
SHP to review the use of the CAADA DASH risk identification checklist in Hillingdon agencies including: the purpose of DASH completion, the adoption of DASH consistently across agencies and in front line practice, the use of DASH as an on-going risk identification tool, and the arrangements for sharing of risk …
Safer Hillingdon Partnership (SHP)
Wigan — recommendation 7
All telephone numbers of agencies available for easy access.
Primary School ‘A’
Wigan — recommendation 4
Schools to have information of agencies available to give to parents undergoing family difficulties.
Primary School ‘A’
Wigan — recommendation 3
Possibility of Safeguarding Officer /Headteacher being informed when parents/carers are undergoing support/ treatment for serious mental health issues.
Primary School ‘A’
Wigan — recommendation 2
A safeguarding children guideline for information sharing following domestic homicide should be developed.
Bridgewater Community Healthcare NHS Foundation Trust
Bridgewater Community Healthcare NHS …
Wigan — recommendation Two
Work with partner agencies to develop a multi-agency information sharing agreement in respect of domestic homicides.
WBSCP
Elmbridge — recommendation 3
Ensure that the agreed intention of providing Police information about vulnerable people to relevant agencies, including schools is promulgated with urgency.
Elmbridge Community Safety Partnership
Leeds — recommendation SACS2
For all agencies involved in the treatment and care of a patient/ client, to have access to a standardised passport/ document which includes details of the patients/clients past history and present circumstances. Such information would include, the patient/clients relationship status, their current living situation, family relationships/ history, potential risk factors …
St Anne’s Community Services
Leeds — recommendation LTHT6
To develop a system to enable to a link of relevant information about domestic abuse between relevant patient records such as family members where there is the same address.
Leeds Teaching Hospitals NHS Trust
Leeds Teaching Hospitals NHS …
Leeds — recommendation LTHT4
To explore how relevant clinical information held by mental health services such a mental health assessments and risk assessments can be communicated to and recorded by LTHT.
Leeds Teaching Hospitals NHS Trust
Leeds Teaching Hospitals NHS …
Cornwall — recommendation 10c
Information regarding episodes where child in care of Local Authority to be shared with General Practitioner and other health professionals. (Note: practice has changed since 1960.s)
Safer Cornwall
South Gloucestershire — recommendation 23
Information sharing at MARAC to be audited to ensure information is shared when it is in the possession of NBT
North Bristol NHS Trust
North Bristol NHS Trust
South Gloucestershire — recommendation 2
Where a victim may have links or associations across Local Authority boundaries, that the MARAC and its participating agencies ensure that the MARAC in the relevant adjoining area and organisations in that area are informed and invited to share information.
Avon and Somerset Constabulary | South …
Avon and Somerset Police
Leeds — recommendation LTHT2
To explore how relevant clinical information held by mental health services such as mental health assessments and risk assessments can be communicated to and recorded by LTHT.
Leeds Teaching Hospitals Trust
Leeds Teaching Hospitals NHS …
Nuneaton and Bedworth — recommendation 9
The MARAC steering group implements the following improvements to MARAC processes and procedures, ensuring that these are all compliant with CAADA guidance and checklists: a. Completes and circulates the revision of the MARAC Operating Protocol b. Completes and circulates the MARAC Information Sharing Protocol c. Improves and re-formats the MARAC …
MARAC Steering Group
Nuneaton and Bedworth — recommendation 4
Safer Warwickshire Partnership Board develops an Information Sharing Protocol, with accompanying guidance, for all partner agencies regarding sharing information within DHRs. This should include guidance on collecting information in a timely way so that any information that cannot be shared with the Panel pre-trial has been secured internally, thus avoiding …
Safer Warwickshire Partnership Board
Harlow — recommendation 15.10.3
All agencies should familiarise themselves with the “7 golden rules of information sharing” as published by HM Government.
All Agencies
Harlow — recommendation 15.10.2
To develop appropriate information sharing protocols that can override the barriers caused by separate IT systems, and the laws regarding data protection.
All Agencies
Harlow — recommendation 15.8.3
Agencies have requested information about previous incidents of domestic abuse to be included on the DV/1 form, however it is unclear whether this would comply with the law regarding the disclosure of spent convictions. More reference should be made to “the 7 golden rules for information sharing” which have been …
Essex Police
Essex Police
Nottingham — recommendation NUH 1
Escalate need for read only access to mental health system (RIO) for NUH patients seen by CAMHS, DPM and RRLP to support communication and information sharing to effectively safeguard.
Nottingham University Hospital
Nottingham University Hospitals NHS …
Somerset — recommendation 20.5
It is recommended that when a disclosure needs to be made to keep a child safe, personnel must clearly evidence who needs to be party to the information in order to act in the best interest of the child.
Children Social Care
Somerset — recommendation 7.2.1
When making a referral, which involves a victim with multiple needs, the referring agency must ensure that as much detail is shared with the new agency in order to support the transition including consideration for travelling to the new service with medication, identification etc... In addition this would include details …
Somerset Integrated Domestic Abuse Service
Cwm Taf — recommendation 7
The Health Board to be asked what the plans are in relation to the implementation of WCCIS and, in the meantime, provide details of how mental health practitioners will have access to both health and local authority records and systems
The Health Board
Kensington and Chelsea — recommendation 9.2.vi
Ensure that information is accessible to those who do not speak or read English with confidence.
RBKC Neighbourhood Management - Housing
Kensington and Chelsea — recommendation i
All key agencies to consider using an interpreter for initial assessments where the person is not fluent in, or prefers to speak in their primary language
All key agencies
Somerset — recommendation 5
To review the Somerset CCG Domestic Abuse Information Sharing project between Police and Primary Care (GPs) during COVID-19 Pandemic 2020. Investigate its wider implementation.
Avon and Somerset Police | Somerset …
Avon and Somerset Police
Hartlepool — recommendation 8
When there is multi-agency involvement in a patient’s case, TEWV to ensure any alerts pertaining to potential risks should be shared across all agencies.
TEWV
Tees, Esk and Wear …
Croydon — recommendation 6.1.3.c
AIR Network to set up processes to receive risk information from referring external organisations. Outcome: same as point above.
AIR Network
Croydon — recommendation 6.1.3.b
AIR Network to review their internal processes regarding the sourcing of external risk information. Outcome: To assess the need to have access to information that would make staff more alert to potential risks. Access to formally recorded known risk information would provide staff with a more holistic picture of an …
AIR Network
Middlesbrough — recommendation 17.23
Guidance to be reissued to staff in relation to information sharing with other agencies in particular the police and MARAC to ensure appropriate information is shared in order to manage risk effectively.
National Probation Service
National Probation Service
Middlesbrough — recommendation 17.18
Details of domestic abuse history obtained from Police systems are routinely recorded in the Non-Disclosure Section of OASys, as well as in the Case Management System in order to ensure that this information is flagged to any member of staff who may need to access the case record.
National Probation Service
National Probation Service
Middlesbrough — recommendation 17.7
Middlesbrough CSP and Durham CSP should seek written assurance from Durham Constabulary and NPS that the failure to share information in this case has been resolved by new processes.
Middlesbrough Community Safety Partnership | Durham …
Ealing — recommendation 1
The Ealing MASH (Multi-Agency Safeguarding Hub) should improve and reinforce the protocol for sharing of critical information, such as the ECS sending CP information to the GP and the GP not being informed of the homicide. Probation should also ensure that when information is received that a perpetrator has moved …
Ealing Children’s Service | National Probation …
National Probation Service
Basildon — recommendation 14
That arrangements are put in place to ensure that AMHPs are able to access relevant and timely information prior to Mental Health Act assessments, including those completed out of normal working hours.
Local Authorities | NHS Trusts
Local Authorities
Basildon — recommendation 11
That information sharing protocols are developed between agencies not included in the MASH project, to enable the sharing of relevant information that may reduce the risk of harm to staff, clients and others.
Agencies not included in the MASH …
Basildon — recommendation 10
That efforts are made to progress the establishment of the Essex Multi-Agency Information Sharing Hub (MASH) to enable health and care agencies to share appropriate information that may help to identify individuals in crisis in future.
Essex Multi-Agency Information Sharing Hub (MASH)
Basildon — recommendation 4
That consideration be given to the establishment of a national database which records all incidents related to mental health concerns. This might include reports of concern to the Police (hoax calls, victims of domestic abuse expressing concern), mental health assessments undertaken by CMHS or agencies working out of hours, diagnoses …
Government
UK Government
New Forest — recommendation 9
Hampshire Constabulary to consider incorporating Domestic Abuse referrals into the Multi Agency Safeguarding Hub (MASH) to protect the most vulnerable victims of domestic abuse and implement and action more action related to repeat crimes.
Hampshire Constabulary
Hampshire and Isle of …
Wiltshire — recommendation 3
In order to share information about vulnerable adults and assess risks at the earliest stage partners should consider building on the MASH model currently being implemented in Children’s Services to include adults at risk.
Wiltshire Safeguarding Adults at Risk
Wiltshire — recommendation 1
To have a formal perpetrator risk assessment that takes into account previous behaviour, current issues and any threats for identifying the level of risk that is posed to the victims and others. This should be initiated by the referring agency and then shared through the ASBRAC network for other agencies …
Wiltshire Anti-Social Behaviour Reduction Conference
Wiltshire — recommendation 2
Police should ensure that Niche is flagged, when persons are MAPPA or MARAC nominal’s, to enable information to be shared with relevant agencies.
Wiltshire Police
Wiltshire Police
Kent — recommendation 13.1
Consideration to be given to widening the communication of personal information in relation to domestic abuse incidents following referrals from Social Services to all frontline health workers/agencies and relevant GP’s that have direct contact with the victim. This will ensure that frontline health staff including General Practitioners are fully briefed …
Local Clinical Commissioning Group
Bristol — recommendation 2
Each agency involved in information sharing from multi agency meetings to dip sample a small number of cases to identify how the information gets shared and whether it is readily available to frontline workers to enable and inform operational activity
Multiple agencies
Somerset — recommendation 30
Effective Information sharing
SCC Adult Social Care
Somerset — recommendation 26
Ensure that the decision not to accept any referral (for voluntary perpetrator programme) is shared with key partners
SIDAS Barnardo’s