Inadequate Pre-Operative Risk Assessment
Insufficient pre-operative assessments and specialist reviews for patients with significant comorbidities, risking complications.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
4 inquiry recs
149 PFD reports
7 committee recs
2 HSSIB recs
12 CQC actions
35 PPO recs
2 IOPC recs
1 IMB rec
1 patient safety alert
1 Scottish FAI
136 PHSO decisions
232 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(4)
IBI-7a(ii) — Tranexamic Acid - Scotland, Wales and NI
Recommendation: In Scotland, Wales and Northern Ireland offering the use of tranexamic acid should be considered a treatment of preference in respect of all eligible surgery.
Gov response: The Scottish Government’s Oversight and Assurance Group (OAG) Chair and Deputy Chair wrote to Health Boards in November 2024 asking them to review practice within their Board and confirm that they are offering tranexamic acid …
Accepted in part
IBI-7a(i) — Transfusion Committees and Tranexamic Acid - England
Recommendation: In England, Hospital Transfusion Committees and transfusion practitioners take steps to ensure that consideration of tranexamic acid be on every hospital surgical checklist; that hospital medical directors be required to report to their boards and the chief executive of their …
Gov response: UK’s governments Recommendation 7 includes an especially complex set of sub recommendations. To ensure a joined up approach across the four nations, experts from across the four nations NHS bodies, blood services and external bodies …
Accepted in part
4 — Reflection period for consent
Recommendation: We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. The GMC should monitor this as part of …
Gov response: Accept in principle Many key organisations, including the GMC, have taken steps to update their guidance, and to confirm that doctors should give patients sufficient time to consider their options before making a decision about …
Accepted in part
BRIS-26 — Provide comprehensive information on risks, alternatives, and outcomes for informed patient consent
Recommendation: As part of the process of obtaining consent, except when they have indicated otherwise, patients should be given sufficient information about what is to take place, the risks, uncertainties, and possible negative consequences of the proposed treatment, about any alternatives …
Unknown
Prevention of Future Deaths reports(149)— showing 50 strongest matches
Annie Jones
Concerns: The coroner noted an inadequate mobility assessment for Mrs Jones, leading to her unsafe placement in a stand aid while non-weight-bearing. Concerns also included insufficient staff awareness of her limitations and safe equipment operation.
Responded
Lucy Kilvert
Concerns: The coroner noted a delay in performing a CT scan of the head for Mrs. Kilvert and raised concerns that NICE Guidelines may insufficiently emphasise the significance of blood-thinning medication in elderly patients who have fallen when considering a CT scan.
Overdue
Jennifer Rushworth
Concerns: The coroner noted lengthy delays in obtaining cardiology reviews and a lack of surgeon input in theatre booking, contributing to operational delays. Concerns also included an insufficient number of surgeons for laparoscopic cases and a query regarding a change in surgical clips.
Pending
Laura Hill
Concerns: Falls Risk Assessments were not carried out for Mrs Hill during her hospital stay, specifically on admission or ward transfer, despite existing staff training on the procedure.
Response (Stockport NHS Foundation Trust): • Nurses involved were formally counselled for failing to follow Trust policy regarding the implementation of the falls risk assessment on admission and its update upon ward transfer. • An … (AI summary)
Responded
Herta Woods
Concerns: Concerns were raised regarding a lack of early senior review for incorrect fluid charting, which contributed to fluid overload, and a failure to record doctor's visits and act on the patient's NEWS score.
Overdue
Nathan Douthwaite
Concerns: The coroner identified that a rectal biopsy might have led to an earlier diagnosis of Hirschsprung's disease, and recommended reviews of NICE guidelines, hospital practices, and potential guidance from the Department of Health.
Response (Department of Health): • NICE stated it would shortly begin a search for evidence to inform a review of its clinical guidance on constipation in children and young people. • NICE confirmed it … (AI summary)
Overdue
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends pose an increased risk of post-operative complications for vulnerable patients.
Overdue
Carol Walker
Concerns: The coroner noted it was not standard practice at Harrogate District Hospital to routinely administer chemical thrombo prophylaxis or undertake formal venous thromboembolism risk assessments for patients with conservatively treated lower limb injuries in casts.
Overdue
Betty Smith
Concerns: The coroner identified insufficient ITU bed capacity due to nursing shortages, inadequate anaesthetic pre-assessment for high-risk patients relying solely on medical records, and the failure to secure a High Dependency Unit bed post-operatively for such a patient.
Overdue
Beryl Walters
Concerns: The coroner raised concerns regarding the use of Cyclizine in patients with severe heart failure, noting cautions in the British National Formulary and the availability of an alternative antiemetic with a different cardiac risk profile.
Overdue
Patricia Mellor
Concerns: The coroner raises concerns that the Medicines and Healthcare Products Regulatory Agency (MHRA) and NICE have not acted on recommendations to update product information warnings for anaesthetic agents and revise pre-operative assessment guidelines concerning Long QT Syndrome.
Overdue
Martin McCabe
Concerns: No falls risk assessment was carried out upon the patient's admission to ward 15, with staff relying on an outdated assessment that did not include crucial information about recent falls and new medication.
Overdue
Stephen Mayoll
Concerns: Out-patients returning to the fracture clinic were not re-assessed under the DVT policy, potentially increasing DVT risk. Additionally, delays in typing doctors' notes meant they were not always available for follow-up appointments.
Response (Portsmouth Hospitals NHS Trust): • Patients returning to the fracture clinic with lower limb injuries will undergo VTE risk factor reassessment at each visit. • A plaster room form is being updated to incorporate … (AI summary)
Responded
David Greenfield
Concerns: The coroner noted staff lacked appreciation for respiratory depression risks in patients with co-occurring drug and alcohol problems. Admission procedures for alcohol detoxification also lacked drug screening, hindering proper risk assessment for those known to take other substances.
Response (Priory Group): • The Priory Group completed an audit of medical staff competencies in specialist wards, providing additional training or transfers as required. • The group amended its Non-Medical Prescribing policy (H21) … (AI summary)
Responded
Robert Stuart and Darren Hughes
Concerns: The coroner identified insufficient transmission of comprehensive donor information and microbiology reports to the transplant centre. Concerns also included the accepting consultant not using the full electronic system and making unilateral decisions without a team approach.
Response (NHS Blood Transport): • NHSBT approved expenditure for an IT development to change how specialist nurses record and transmit data electronically to transplant centres, with full operation expected by April 2016. • The … (AI summary)
Overdue
Neil Westerman
Concerns: A junior doctor performed the pre-operative assessment, leading to the consultant being unaware of vital information, and operation notes lacked details of equipment used. There were also insufficient junior doctors on duty, particularly at night.
Response (Stockport NHS Trust): • Steps were taken with the individual surgeon to prevent a recurrence of non-standard pre-operative assessments, and the case was discussed at a Morbidity & Mortality meeting and with the … (AI summary)
Responded
Nicola Tweedy
Concerns: The coroner noted the absence of specific aftercare leaflets provided to the patient, the consistent non-completion of the Thromboprophylaxis Risk Assessment form, and incomplete nursing notes and checklists at the point of discharge.
Response (Norfolk Norwich University Hospitals): • An action plan was produced prior to the inquest. • External inspection confirmed the implementation of actions identified in the plan. • The Trust will continue to monitor the … (AI summary)
Response (Department of Health): • The Department reported that an independent external inspection found the Norfolk and Norwich University Hospital NHS Foundation Trust had implemented an Action Plan to address the issues raised. • … (AI summary)
Responded
Ronald Smith
Concerns: The coroner noted the absence of a clear and accessible protocol for staff to access equipment for flexible sigmoidoscopies out of hours. This issue persisted 18 months after the death, indicating a need for expedited action.
Overdue
Anthony Geerts
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response (Brighton and Sussex University Hospitals NHS Trust): • The trust centralised the fractured neck of femur service at Princess Royal Hospital, eliminating patient transfers between sites. • A Clinical Nurse Practice Educator was recruited, integrated documentation introduced, … (AI summary)
Overdue
Patricia Holmes
Concerns: The A&E doctor's assessment did not adequately consider the risk of internal bleeding for a patient with trauma and multiple fractured ribs, who was also receiving anticoagulation therapy.
Response (East Kent University Hospitals NHS Trust): • The Trust has implemented an approved Chest Injury Trauma Algorithm across its emergency departments. • The algorithm directs staff to consider the reversal of anticoagulation medication and to seek … (AI summary)
Responded
Karen O’Brien
Concerns: The coroner noted concerns regarding a clinical determination made by SEPT without a face-to-face mental health assessment or sufficient inquiry, overriding the patient's GP's request. The report also invited NICE to reconsider its guideline on this matter.
Overdue
Rachel Hollister
Concerns: Medical staff and porters were unaware of or did not follow Health Board protocols, and the major obstetric haemorrhage protocol did not align with Royal College guidelines.
Overdue
Casey Garrett
Concerns: The coroner noted inappropriate midwifery care by a student midwife, including insufficient fetal monitoring and CTG misinterpretation, alongside a failure to escalate care. This raised questions about Bedford Hospital's suitability as a clinical learning environment.
Response (Health Education East of England): • Health Education East of England confirmed it would continue to collaborate with Bedford Hospital NHS Trust and the University of Bedfordshire to ensure the delivery of an action plan. … (AI summary)
Overdue
Mary James
Concerns: The coroner noted inadequate monitoring of INR levels and uncertainty regarding Warfarin adherence for a patient with dementia. There were also concerns about communication gaps between the INR Unit, care home, and GP, and a missed opportunity for hospital admission to adjust anticoagulation therapy.
Overdue
Eileen Smith
Concerns: Failings in nursing care were identified for a patient with learning disabilities, alongside inadequate communication with their carers and family. The report also raised concerns about assumptions made regarding the health of individuals with learning disabilities.
Response (Department of Health): • The Trust carried out a Serious Incident Investigation, produced a report detailing failings, and implemented an action plan with changes to prevent recurrence. • The Trust produced a hospital … (AI summary)
Responded
Barry Pike
Concerns: The coroner's specific concerns are detailed within an enclosed report authored by Dr Stephen Hoole, which was referenced in the PFD.
Overdue
Sharon Henshall
Concerns: The coroner identified the absence of a venothromboembolism risk assessment model in the Emergency Department for patients discharged with lower limb immobilisation, noting a 'postcode lottery' in prophylaxis across different Trusts and inconsistency with NICE guidance.
Overdue
Frederick Sutton
Concerns: The coroner identified suboptimal hospital staffing levels, issues with staff shortage escalation procedures, and insufficient staff training in drug administration and cardiac arrest response.
Overdue
Rosalind Baird
Concerns: The coroner noted a lack of a formal national monitoring scheme for inexperienced surgeons carrying out procedures. Consideration should be given to developing a national scheme, using the Queen Alexandra Hospital's model as an example of good practice.
Overdue
Rosina Drury
Concerns: The coroner noted that the absence of a pre-operative orthogeriatric review for patients with a fractured neck of femur may lead to the use of cemented hemiarthroplasty, which carries a risk of mortality from bone cement implantation syndrome.
Overdue
Rebecca Jones
Concerns: The coroner identified that the Section 136 assessment for Rebecca Jones was not conducted within the expected three-hour timeframe. This delay occurred because urgent assessments were required for other vulnerable persons, indicating a potential capacity issue at the facility.
Response (Department of Health): • NHS England committed to spending £15 million in 2016/17 to boost provision and improve standards in health-based places of safety. • NHS England stated it would develop commissioning guidance … (AI summary)
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Darren Jones
Concerns: Current protocols for when to seek renal advice for patients, particularly those who have undergone transplants, are limited, and there are questions regarding the availability of immunosuppressant medication at short notice.
Overdue
Thelma Clarkson
Concerns: The coroner noted that the NICE Head Injury Pathway does not include Clopidogrel as a trigger for a CT scan after a head injury, unlike Warfarin, despite the increased risk of bleeding. This omission may affect timely diagnosis and treatment.
Overdue
Stephen Adams
Concerns: The coroner noted that the suicide risk assessment section on the Mental Health Liaison Team's risk assessment document was frequently left incomplete, requiring risk to be inferred from actions rather than explicitly recorded.
Overdue
Bryan Catanach
Concerns: The coroner raised concerns about communication difficulties between clinicians and hospital trusts, leading to delayed patient transfers and reviews. Issues also included a patient falling from bed due to inadequate supervision for an unstable neck fracture.
Response (Bryan Catanach): • The Trust refreshed and reaffirmed its receiving and first line management processes for emergency patients, including piloting a 'consultant of the week' model for spinal services. • Proforma-based documentation … (AI summary)
Responded
Euphemia Aldred
Concerns: The report raises concerns that were not detailed in the excerpt.
Overdue
Ronald Bentley
Concerns: The coroner identified a lack of widespread awareness among cardiologists and device manufacturers regarding the risk of air entering the vascular system during a specific cardiac procedure when performed under conscious sedation. This unknown risk could lead to future complications for patients at other Cardiac Centres.
Response (BCIS): • BCIS circulated the report to its members via its official newsletter. • BCIS passed the report details to the British Heart Rhythm Society (BHRS) for circulation to electrophysiology colleagues. (AI summary)
Overdue
Marjorie Booth
Concerns: The coroner raised concerns regarding a hospital policy that does not routinely perform CT scans for elderly patients with suspected fractures due to radiation risk, despite the higher risk of missing such injuries. The report asks if this policy can be amended.
Overdue
Lincoln Brady
Concerns: The coroner noted that non-correlating examination results were not further investigated with an ultrasound, leading to an undiagnosed breech presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): • The Trust implemented 'Lincoln's Rule' in January 2015, establishing a low threshold for considering presentation scans and highlighting red flags for further investigation. • Policies and training for managing … (AI summary)
Responded
David Aughton
Concerns: The concerns text for this report is incomplete, so specific issues cannot be identified.
Overdue
Karen Ravenscroft
Concerns: The concerns text for this report is incomplete, so specific issues cannot be identified.
Overdue
Rhianne Barton
Concerns: The coroner identified a lack of obstetric consultant supervision and a failure to consider surgical causes for abdominal pain following bariatric surgery. Concerns were also raised about poor clinical documentation, unaddressed urine dipstick findings, and a lack of specific guidance for managing pregnancy post-bariatric surgery.
Response (Ashford and St Peters Hospital NHS Trust): • Changed consultant working practices to facilitate timely review of patients on Joan Booker Ward, with a default plan for consultants to review patients under their care daily. • Produced … (AI summary)
Overdue
Kirsty Childs
Concerns: Concerns were raised regarding the absence of a standard question to identify previous patient contacts, the selection of incorrect questionnaires by non-medically qualified staff, and no review of earlier calls within NHS Direct.
Overdue
Joshua Knox-Hooke
Concerns: The coroner identified inadequate observation of a patient at risk of self-harm and frequent instances of patients leaving A&E before psychiatric assessment. It was also noted that a triage nurse was unaware of Mental Health Act holding powers.
Response (Knox Hooke): • The Trust implemented a Mental Health Triage Form and prioritisation tool to identify and prioritise high-risk mental health patients. • Training for front-line clinical staff on the Mental Health … (AI summary)
Responded
Jean Stockley
Concerns: The coroner noted that a junior doctor did not review the patient despite a rapidly deteriorating NEWS score, potentially attributing symptoms to anxiety, which suggests a training need. It was also unclear whether the correct doctor was contacted when the patient's condition worsened.
Response (Brighton and Sussex University Hospitals NHS Trust): • The ward adopted the SBAR protocol, including a special form for documenting critical telephone conversations. • The Critical Care Outreach Team implemented a 24-hour service from June 2015, and … (AI summary)
Responded
Michael Blow
Concerns: The coroner noted concerns that an INR test was not performed to inform treatment, and warfarin was restarted based on an outdated reading. There is a need to clarify protocols for junior doctors regarding treatment reversal and restarting warfarin.
Overdue
Harry Glibbery
Concerns: The coroner noted a doctor did not prescribe Clexane according to protocol, and this error was not identified during pharmacy reviews. Concerns were also raised about difficulties in weighing patients, which is crucial for weight-dependent medication.
Response (Plymouth Hospital NHS Trust): • The Trust stated that protocols for therapeutic Clexane would be reviewed by the Thrombosis Committee, and clear guidance would be disseminated. • An electronic prescribing and medicines administration (ePMA) … (AI summary)
Responded
Diana Ritchie
Concerns: The coroner identified missed opportunities to escalate care due to un-reported and inaccurately recorded NEWS scores, alongside insufficient frequency of observations during deterioration. A wider need for training on proper NEWS use within the Trust was also highlighted.
Response (Brighton and Sussex University NHS Trust): • The Trust provided additional training and familiarisation to ward staff regarding observation completion and appropriate escalation. • The Trust circulated internal communications, including a "Spotlight on Safety" message and … (AI summary)
Responded
George Watson
Concerns: The coroner identified an unsatisfactory patient discharge process, specifically regarding medication provision, and unclear procedures for staff allocation and managing staff absence. There was also a call for further evidence on improved investigatory processes, including police cooperation.
Overdue
Select committee recommendations(7)
#7 —
Recommendation: Early in the pandemic, the National Institute for Health and Care Excellence’s (NICE) critical care guidelines and doctors’ inappropriate or blanket use of “Do not attempt resuscitation” (DNAR) notices were potentially discriminatory. While we welcome actions taken swiftly to address …
Response attribution not verified
#18 — Ensure leasehold extension legislation applies equally to all shared ownership properties and leaseholders.
Recommendation: Finally, the Government should ensure that any legislation passing through Parliament which has provisions to reduce the cost of, and simplify, the process of leasehold Shared Ownership 41 extension (for example, as in the Leasehold and Freehold Reform Bill) also …
Response attribution not verified
#17 — Update Homes England Capital Funding Guide to require specialist advice teams for shared owners.
Recommendation: We urge Homes England to update its Capital Funding Guide for shared ownership to specify that providers should only be selling shared ownership properties on the condition they set up and maintain specialist teams of professionals who can provide accurate, …
Response attribution not verified
#16 — Ensure appropriate advice is readily available for shared owners making significant financial decisions.
Recommendation: It is unacceptable that shared owners are having to make significant financial decisions without appropriate advice being readily available, and we believe the Government must act to remedy this. We also believe that it is unacceptable that shared owners do …
Response attribution not verified
#15 — Mandate Homes England ensure providers include lease guidance and signposting in Key Information Documents.
Recommendation: Homes England should ensure that providers include simple guidance on lease arrangements within the Key Information Documents distributed to shared owners, including information on how rights and responsibilities are allocated and guidance on how to extend the lease. It should …
Response attribution not verified
#14 — Shared owners lack access to advice on leasehold tenure and lease extension complexities.
Recommendation: It is clear that many shared owners lack access to advice and guidance which can explain to them clearly and impartially the complexities of leasehold tenure and their rights and responsibilities under their shared ownership lease, as well as advise …
Response attribution not verified
#29 — Suspend notices of intent for Rwanda removals and review initial screening procedures thoroughly.
Recommendation: We are deeply concerned that the Home Office’s case-by-case risk assessments prior to issuing notices of intent to remove potentially inadmissible asylum claimants to Rwanda appear to be inadequate. There is evidence that a significant number of vulnerable people, to …
Response attribution not verified
HSSIB safety recommendations(2)
Surgical care of NHS patients in independent hospitals
It may be beneficial if NHS and independent sector organisations delivering NHS-funded surgical interventions reviewed their procedures and practice in light of the published 2021 guidance for ‘Preoperative Assessment and Optimisation for Adult Surgery’. Such a review should take into …
Safety Observation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that the Royal College of Anaesthetists reviews standards for pre-assessment services, including their purpose, the required observations and examinations, and competencies of staff undertaking this work.
Safety Recommendation
NCEPOD recommendations(6)
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
CQC inspection actions(12)
Clatterbridge Hospital
The service must ensure that staff comply with all aspects of the surgical safety checklist.
Must Do
Clifton Hospital
The trust should consider acting to increase the normal birth rate and ensure that elective caesarean sections have a documented clinical indication for early delivery.
Should Do
BMI Southend Private Hospital
The provider must ensure that the need for VTE screening is assessed by the service and administered to patients as per the service’s policy in line with national best practice.
Must Do
BMI Southend Private Hospital
The provider must ensure that risks to patients are identified through surgical pre-assessment prior to surgery being undertaking under local anaesthetic.
Must Do
Northern General Hospital
The trust should consider expanding the audit programme to include the assessment of pain and the use of preoperative fasting.
Should Do
Kidderminster Hospital and Treatment Centre
Ensure that all admission letters for elective patients ask them to highlight if they have been an inpatient in hospital within the last 12 months.
Should Do
Andover War Memorial Hospital
The provider should act and review the process for fasting pre-operatively in line with guidelines.
Should Do
Andover War Memorial Hospital
The service should consider consistency with the World Health Organisation Safer Surgery Checklist.
Should Do
Meet The Baby
The provider should ensure that appropriate further consent procedures are in place before transvaginal scans are introduced as a service.
Should Do
Hazelwood
We recommend the provider takes advice from two people's GPs to determine if they are of suitable weight for their height and to assess whether specialist nutritional advice is required.
Should Do
Meet The Baby
The provider should consider asking women whether they have a latex allergy before they attend for a scan in order that appropriate measures can be taken to prevent them from coming into contact with latex in the clinic.
Should Do
Margaret Clitherow House
The registered person is recommended to take advice from a suitably qualified person and follow best practice in relation to the monitoring of risks associated with people's intake of fluids.
Should Do
PPO death in custody recommendations(35)
The Operational Security Group Director for HMPPS
The Operational Security Group Director for HMPPS should monitor, over the next three months, how many prisoners at HMP Highpoint are escorted to hospital without restraints (for inpatient admissions and outpatient appointments) and report back to the Ombudsman.
The Governor and Head of Healthcare (HMP Highpoint)
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical information …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare and security teams share appropriate information and work collaboratively to complete escort risk assessments, to ensure restraints decisions are appropriate.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare input into escort risk assessments is based on up-to-date medical information and is clear and sufficiently detailed.
The Governor
The Governor should ensure that prison staff understand that medical information about a prisoner must be sought and properly considered when deciding whether to use restraints and in cases where a medical objection is disregarded or is not obtained the …
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints, that healthcare staff complete the medical information section of the escort risk …
The Governor
The Governor should ensure that authorising managers understand the legal position on the use of restraints and that assessments fully take into account the health of a prisoner and are based on the actual risk the prisoner presents at the …
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints, that healthcare staff complete the medical information section of the escort risk …
The Head of Healthcare
The Head of Healthcare should review the systems and processes for training and supporting staff to complete escort risk assessments for patients requiring emergency hospital admission.
The Governor of HMP Swaleside
The Governor should ensure that all staff completing escort risk assessments for prisoners taken to hospital involve healthcare input and authorisation by a Governor or nominated equivalent, in line with the External Escorts Policy Framework 2022.
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: staff are using the current escort risk assessment template, as outlined in the policy framework.
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: all staff involved in the escort risk assessment process receive training on the Graham judgment and have a clear understanding of how it …
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: healthcare staff are routinely involved in the escort risk assessment process, taking a prisoner’s current medical condition into consideration, including how this impacts …
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: in line with policy, a thorough escort risk assessment is completed for every non-life-threatening emergency hospital escort;
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking and reviewing risk assessments for prisoners taken to and admitted to hospital understand the legal position, that assessments fully take into account prisoners’ health and are based on …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners who are attending hospital appointments: • complete the risk assessment documents in full, clearly setting out their rationale for the decisions; and • understand …
The Head of Healthcare
The Head of Healthcare should ensure that a full set of clinical observations are taken during reception screening in accordance with NICE guidance and any anomalies escalated to a senior clinician.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff completing and authorising risk assessments justifying the use of restraints on prisoners taken to hospital understand the legal position, and that assessments fully take into account the health of …
The Director
all staff undertaking risk assessments for prisoners attending hospital understand the legal position on the use of restraints, including that their assessments fully take into account the prisoner’s health and mobility, and are based on the actual risk the prisoner …
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that escort risk assessments fully take into account the health of a prisoner and are based on the actual risk he presents at the time.
The Governor
The Governor should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that authorising managers show that they have taken this information into account when assessing a …
The Operational Manager
The Operational Manager should ensure that prisoners in segregation are managed in line with PSO 1700, in particular: • Prisoners on an ACCT are segregated only in exceptional circumstances. • Where a segregated prisoner becomes subject to ACCT procedures, a …
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical …
The Governor
The Governor should ensure that the medical sections of risk assessments are fully completed, and in circumstances where this is genuinely not possible, the authorising officer should indicate why, and when restraint levels will be reassessed.
The Director General of Prisons
The Director General of Prisons should issue national guidance on risk assessments for clinically high-risk prisoners, to ensure that protective measures are fully considered for those employed as cleaners, or in other roles which significantly increase the possibility of exposure …
The Governor
The Governor should review whether the quality assurance process for escort risk assessments is sufficiently robust and consider introducing SLT review of a random sample to identify any ongoing issues.
The Head of Healthcare at Isle of Wight
The Head of Healthcare at Isle of Wight should ensure that staff consider using clinical hold where a prisoner is awaiting surgery for a life-threatening condition and record this in the medical records.
The Governor of HMP Hull
escort staff should question the escort risk assessment and review previous assessments if there are clear indications that restraints should not be used;
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff accurately reflect their professional opinion on restraint risk assessment forms, that there are clear and considered conversations between healthcare and prison staff about a prisoner’s risk where necessary and that …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that: • healthcare staff complete the healthcare section of the escort …
The Governor
The Governor should ensure that all staff undertaking and reviewing risk assessments for prisoners admitted to hospital understand the legal position on the use of restraints, that assessments fully take into account the prisoner’s health and mobility and are based …
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: • healthcare staff complete the medical information …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints.
The Governor of HMP Wormwood Scrubs
The Governor should review Wormwood Scrubs’ policy on escort risk assessments for emergency hospital journeys to ensure that staff take account of a prisoner’s presenting medical condition, as well as public protection factors, when considering the level of restraints.
The Head of Healthcare
ensuring requests for clinical investigations, such as requests for chest X-rays, are actioned promptly
IOPC learning recommendations(2)
Recommendation - Metropolitan Police Service, November 2020
The IOPC recommends the Metropolitan Police Service reviews and amends their stop and search policies, procedures and training to include a routine risk assessment of the physical environment in which the individual has been stopped, and that this is considered …
Recommendation - Bedfordshire Police, November 2020
The IOPC recommends that Bedfordshire Police should review and amend their policy and guidance regarding the transportation of vulnerable individuals with single crewed officers. The same policy, guidance, risk assessments and safeguarding considerations for those arrested or formally detained should …
IMB individual recommendations(1)
National patient safety alerts(1)
PHSO casework decisions(136)
P-003007 — Lewisham and Greenwich NHS Trust
The Trust failed to communicate risks considering her memory, did not X-ray post-op, and delayed diagnosing a displaced femur, causing prolonged pain and long-term mobility issues.
NHS in England
Upheld
Sep 2024
P-001638 — Manchester University NHS Foundation Trust
Mr R complained an angiogram on his father was unnecessary and rushed, and complications were mishandled, leading to his father's death.
NHS in England
Partly Upheld
Sep 2022
P-001846 — Newmedica
Mr Y complained Newmedica's care after cataract removal resulted in fluid leakage and infection, causing him excruciating pain, impaired vision, and distress.
NHS in England
Dec 2022
P-001751 — Royal United Hospitals Bath NHS Foundation Trust
Mr D complained he was not fully informed of all risks, including major surgery, associated with a polypectomy during a colonoscopy, leading to a perforated colon.
NHS in England
Partly Upheld
Jan 2023
P-001753 — King's College Hospital NHS Foundation Trust
The Trust did not perform a urine test before Mr E's cystoscopy, as advised, which he believes led to a bladder infection and post-procedure discomfort.
NHS in England
Partly Upheld
Jan 2023
P-002558 — A practice in the Teignbridge area
Mr I complained the Practice took a functional approach to his rib pain, failing to order appropriate investigations, leading to ongoing pain and significant life impact.
NHS in England
Apr 2024
P-002638 — East Kent Hospitals University NHS Foundation Trust
Miss R complained the Trust failed to assess her father's swallow and did not isolate him, leading to aspiration pneumonia and COVID-19, which she believes contributed to his death.
NHS in England
Partly Upheld
May 2024
P-003037 — The Princess Alexandra Hospital NHS Trust
The Trust ignored her concerns about an IV cannula not being properly in place during a CT scan, causing contrast dye leakage and burns. She also received inadequate information about her injury.
NHS in England
Oct 2024
P-003054 — County Durham and Darlington NHS Foundation Trust
Mr K complained the Trust failed to perform an ultrasound scan and administered anticoagulant medications without checking for internal bleeding, believing these actions hastened his wife's death.
NHS in England
Oct 2024
P-003090 — University Hospitals of North Midlands NHS Trust
Mrs M complained the Trust did not appropriately act on her mother's chest pains or blood test results, delayed an ECG, inappropriately administered medication, and ignored her call bell, resulting in her avoidable death.
NHS in England
Upheld
Oct 2024
P-004325 — University Hospitals Birmingham NHS Foundation Trust
Complaint alleged inappropriate treatment of pregnancy-induced hypertension, inadequate monitoring, failure to administer epilepsy medication, and sterilisation performed without informed consent during childbirth.
NHS in England
Upheld
Nov 2025
P-004367 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs D complained about poor care during childbirth, including struggling with forceps, improper episiotomy stitching, and delayed cleaning/dressing of her daughter's facial wound, causing permanent scarring and distress.
NHS in England
Nov 2025
P-004407 — Shrewsbury and Telford Hospital NHS Trust
Miss X complained she was left alone to give birth, false records were made, she was given incorrect prognosis about her baby's life, and received no prenatal care until 21 weeks, leading to her baby's premature death and her PTSD.
NHS in England
Nov 2025
P-004421 — St George's University Hospitals NHS Foundation Trust
Mr F complained the Trust failed to advise him of the risks of penile straightening surgery, resulting in a shorter penis and inability to climax, causing physical and emotional impact.
NHS in England
Partly Upheld
Dec 2025
P-004692 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Mrs Y complained the Trust did not inform them of rectovaginal fistula risk from an Altemeier procedure and delayed follow-up appointments, worsening her mother's condition.
NHS in England
Partly Upheld
Jan 2026
P-001097 — University Hospitals Sussex NHS Foundation Trust
Mrs U complained she did not receive planned sedation for a procedure and was not offered the option to reschedule, causing severe pain and distress.
NHS in England
Partly Upheld
Aug 2021
P-001196 — University Hospitals Sussex NHS Foundation Trust
Mrs W complained the Trust mismanaged her severe back pain, stopping medication and ignoring her history, leading to cancelled surgery and permanent paralysis.
NHS in England
Oct 2021
P-001271 — A hospital in the Essex area
Mrs R complained about ongoing pain and limited mobility after a hip replacement operation in June 2018, hindering her daily activities and hobbies.
NHS in England
Jan 2022
P-001276 — East Suffolk and North Essex NHS Foundation Trust
Mrs T complained the A&E department failed to refer her for an X-ray or provide appropriate treatment after a fall. This led to a delayed jaw fracture diagnosis, prolonged pain, and potential permanent issues.
NHS in England
Upheld
Jan 2022
P-001341 — Leeds Teaching Hospitals NHS Trust
Mrs E complained the Trust failed to communicate about MRSA decolonisation and did not advise stopping medication. She also alleged hospital errors in booking and incorrect isolation advice.
NHS in England
Partly Upheld
Mar 2022
P-001511 — A healthcare provider in the Nottingham area
Mr D complained about a delayed urgent dermatology appointment due to an administrative error and a consultant prescribing medication for vasculitis without prior examination or biopsy.
NHS in England
Partly Upheld
Jul 2022
P-001587 — Stockport NHS Foundation Trust
Mrs A complained her kidney stent replacement surgery was incorrectly performed, causing physical pain, emotional distress, and a loss of trust in the Trust.
NHS in England
Aug 2022
P-001686 — Surrey and Sussex Healthcare NHS Trust
Mr O complained the Trust did not properly assess Mrs O and failed to carry out a back scan or X-ray, which he believes prevented an early diagnosis of her tumours and shortened her life.
NHS in England
Oct 2022
P-001766 — Leeds Teaching Hospitals NHS Trust
Ms P complained the Trust missed opportunities during antenatal ultrasound scans to identify her son's heart condition, which she believes could have saved his life.
NHS in England
Jan 2023
P-001735 — Guy's and St Thomas' NHS Foundation Trust
Ms R complained the Trust failed to consider her family history in a risk assessment and did not offer a BRCA gene mutation test, which she believes led to a delayed breast cancer diagnosis.
NHS in England
Jan 2023
P-001874 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs B complained a junior doctor gave spinal anaesthetic without consent, potentially causing non-epileptic seizures, and a nurse caused pain during a seizure.
NHS in England
Mar 2023
P-001906 — Moorfields Eye Hospital NHS Foundation Trust
Miss W complained the Trust failed to inform her of cataract surgery risks, the doctor ruptured her eye's posterior capsule without reporting it, and she was not informed about hospital transport.
NHS in England
Mar 2023
P-003282 — Somerset NHS Foundation Trust
Mrs L complained about inadequate consent for a breast biopsy, failure to disclose a complication (a new lump) immediately, and dismissal of her concerns post-procedure.
NHS in England
Partly Upheld
Apr 2023
P-001980 — University Hospitals of Derby and Burton NHS Foundation …
Mr A complained the Trust burned his back during jaw surgery and failed to provide appropriate aftercare, causing prolonged pain and mental trauma. He sought an explanation and compensation.
NHS in England
May 2023
P-002012 — Birmingham Women's and Children's NHS Foundation Trust
The Trust provided inadequate assessments and treatment before her cancer diagnosis, caused a cyst rupture during surgery, and communicated poorly.
NHS in England
Jun 2023
P-002106 — Circle Health Group
Mr N complained the Group failed to properly prepare for lipoma removal surgery, leading to an abandoned procedure, same-day discharge without aftercare, and an unhealed wound.
NHS in England
Jul 2023
P-003886 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs X complained the Trust did not provide adequate pain relief or stop a hysteroscopy when it became too painful, causing distress and trauma.
NHS in England
Jul 2023
P-003893 — Barking, Havering and Redbridge University Hospitals NHS Trust
A sister complained the Trust failed to explain DVT risks to her brother, mismanaged his symptoms in ED, and missed a DVT diagnosis, allegedly leading to his preventable death.
NHS in England
Upheld
Oct 2023
P-002282 — University Hospitals of North Midlands NHS Trust
After quadruple bypass surgery, Mr U suffered a major bleed requiring further surgery after a junior nurse turned him on his side.
NHS in England
Nov 2023
P-002393 — Imperial College Healthcare NHS Trust
Miss L complained about eye operations, alleging they were done without anaesthetic, her retina was torn, communication was poor, and silicone oil was left in her eye.
NHS in England
Jan 2024
P-002473 — University Hospitals of Derby and Burton NHS Foundation …
Mrs H complained staff failed to treat her UTI, gave her a cervical stitch with a UTI, misinterpreted a scan, didn't remove the stitch correctly, lacked equipment for delivery, placed her with pregnant women, and sent wrong blood test results, alleging these caused her baby's death.
NHS in England
Feb 2024
P-002483 — University Hospitals Birmingham NHS Foundation Trust
Mrs O complained nurses mishandled her husband's oxygen, causing cardiac arrest, and an inappropriate, failed pleural aspiration led to a lung puncture and his death.
NHS in England
Feb 2024
P-002441 — Frimley Health NHS Foundation Trust
Ms D complained Trust A wrongly prescribed medication leading to her father's death, and Trust B failed to investigate symptoms or provide adequate hydration/nutrition.
NHS in England
Partly Upheld
Feb 2024
P-003311 — County Durham and Darlington NHS Foundation Trust
Mrs E complained her surgeon failed to warn her about the permanent loss of sensation following a hysterectomy, causing distress and impacting her ability to cope and work.
NHS in England
Partly Upheld
Feb 2024
P-003286 — East Sussex Healthcare NHS Trust
Miss H complained the Trust failed to inform her of long-term complications of an endometrial ablation and delayed her hysterectomy for years, causing intense pain and distress.
NHS in England
Partly Upheld
Mar 2024
P-002518 — A practice in the Oxfordshire area
Mrs U complained the Practice did not correctly assess or complete medical tests on her mother between January and April 2022 before her death.
NHS in England
Mar 2024
P-002541 — Royal Devon University Healthcare NHS Foundation Trust
Ms V complained staff in A&E did not properly assess her or provide follow-up advice after an accident, leading to lasting cognitive, emotional, and behavioural issues. She sought apology and service improvements.
NHS in England
Upheld
Apr 2024
P-002777 — Countess of Chester Hospital NHS Foundation Trust
Miss EB complained staff performed a bladder investigation despite a severe infection, leading to sepsis, and her mother was left untreated in ED for hours, causing a coma.
NHS in England
Jul 2024
P-002809 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss B complained about her mother's care during two admissions, including pressure ulcer deterioration, a missed MRI, and mischaracterisation of dementia, which she believed led to her mother's premature death.
NHS in England
Jul 2024
P-002948 — Surrey and Sussex Healthcare NHS Trust
Miss U complained the Trust performed an inappropriate assessment of her cousin, Mrs I, and wrongly discharged her with pneumonia, leading to her deterioration and eventual death.
NHS in England
Partly Upheld
Sep 2024
P-003083 — George Eliot Hospital NHS Trust
Staff delayed checking preoperative samples, discharged partner without treatment for a broken hip, gave no condition updates, prohibited family visits, and didn't assist with bed transfers.
NHS in England
Oct 2024
P-003167 — A practice in the Bradford area
Mrs O complained a GP did not provide a consent form and performed a wrist steroid injection incorrectly, hitting a nerve and causing pain, numbness, and ulcers.
NHS in England
Nov 2024
P-003221 — University Hospital Southampton NHS Foundation Trust
Mrs F complained her father received excessive warfarin and faced delayed CT scans after a fall, worsening a brain bleed and contributing to his death. She also cited a lack of fall prevention improvements.
NHS in England
Not Upheld
Dec 2024
P-003202 — Blackpool Teaching Hospitals NHS Foundation Trust
Mr R complained the Trust gave his mother incorrect doses of Midazolam, did not discuss a Do Not Attempt Resuscitation Order, and wrongly placed her on end-of-life care.
NHS in England
Not Upheld
Dec 2024
P-003353 — Nottingham University Hospitals NHS Trust
Mr L complained the Trust administered chemotherapy to his father, Mr A, when he was too unwell, accelerating his death and causing Mr L significant distress.
NHS in England
Partly Upheld
Feb 2025
LGO / SPSO decisions(232)
NIPSO-19483 — Northern Health and Social Care Trust
We partially upheld a complaint that a patient contracted sepsis because he was released too early from Antrim Area Hospital. We asked the hospital to apologise for its failings, and to review its procedures on discharge of patients from the ward in question.
NIPSO (NI Public Service…
Health & Social Care
Aug 2021
NIPSO-202003412 — Western Health and Social Care Trust
We upheld a complaint from a woman who said she did not give her consent to a surgical procedure. We also found the Trust did not follow the right procedure when it decided the case did not meet the threshold for a Serious Adverse Incident investigation.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Aug 2024
NIPSO-202006867 — Northern Health and Social Care Trust
The Northern Trust should not have left it to the day of the surgery to explain to a patient the potential complications. The patient said that if she had known the possible consequences she would not have given her consent.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Aug 2025
NIPSO-18545 — Northern Health and Social Care Trust
The care and treatment provided to a complainant by the Accident & Emergency Department at Causeway Hospital was 'in accordance with good medical practice.'
NIPSO (NI Public Service…
Health & Social Care
Jul 2000
NIPSO-202000196 — Western Health and Social Care Trust
We asked the Western Health Trust to reflect on what it might have done differently in the treatment of an elderly patient in Altnagelvin Hospital.
NIPSO (NI Public Service…
Health & Social Care
Aug 2022
PSOW-202106222 — Betsi Cadwaladr University Health Board
Mrs A complained about her nursing care during an admission to Ysbyty Glan Clwyd after fracturing her spine in a fall. Mrs A said that the Health Board failed to maintain spinal precautions (“SPs” – to stop movement of the spine to prevent injury to the spinal cord) causing her …
PSOW (Public Services Om…
Health
Sep 2022
PSOW-202306571 — Powys Teaching Health Board
Ms X complained about the standard of care provided to her father, Mr Y, when he was an inpatient at Bronllys Hospital, which is a GP-led hospital service. Specifically, Ms X complained that doctors should have diagnosed Mr Y’s heart failure sooner and arranged an earlier transfer to a different …
PSOW (Public Services Om…
Health
Not Upheld
May 2024
PSOW-202401586 — Swansea Bay University Health Board
Mr C complained about care provided to his mother, Mrs D, by Swansea Bay University Health Board in May 2023. Specifically, he was concerned that a consultant psychiatrist had noticed that his mother had suffered a Transient Ischaemic Attack (“TIA” – also known as “mini strokes”, they are caused by …
PSOW (Public Services Om…
Health
Sep 2024
PSOW-202408596 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board failed to respond to the complaint raised in February 2024. The Ombudsman found that the Health Board had failed to respond to Mrs X’s complaint. The Ombudsman stated that this caused uncertainty and frustration for Mrs X. The Ombudsman decided to …
PSOW (Public Services Om…
Health
Apr 2025
PSOW-202408733 — Aneurin Bevan University Health Board
Mrs A complained that Aneurin Bevan University Health Board had failed to address her concerns raised in August 2024 and had failed to complete a second investigation into the sad death of her son. The Ombudsman obtained further information from the Health Board and decided that although Mrs A was …
PSOW (Public Services Om…
Health
Apr 2025
NIPSO-202000460 — Belfast Health and Social Care Trust
A patient was in pain for longer than necessary because of delays by the Belfast Trust to obtain the results of a private MRI scan.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Feb 2023
NIPSO-201916274 — GP
We investigated whether an increase in a man’s prescription caused him to attend hospital the following day. We found the Practice’s increase in the dose fell within the prescribed limits.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Mar 2024
NIPSO-202401489 — Northern Health and Social Care Trust
We upheld a complaint from a patient who claimed that the delay in her surgery left her with a permanent disability. We also found that the Trust failed to communicate with her about her care and treatment.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2026
PSOW-202103038 — Betsi Cadwaladr University Health Board
Mrs X complained that the Health Board had not provided her with a response to her complaint relating to the loss of her son’s blood samples. He had been undergoing investigations and she had received no explanation as to how the samples had been lost. The Ombudsman decided that the …
PSOW (Public Services Om…
Health
Aug 2021
PSOW-202002703 — Betsi Cadwaladr University Health Board
Mr Y complained that the Health Board: (a) Failed to report on an X-ray taken at his wife’s (Mrs Y) attendance at Glan Clwyd Hospital Emergency Department (“ED”) on 26 October 2019. He said this delayed appropriate medical management resulting in a further ED admission on 4 November. Had Mrs …
PSOW (Public Services Om…
Health
Upheld
Aug 2021
PSOW-202100242 — Aneurin Bevan University Health Board
Ms B and Mr C complained that Aneurin Bevan University Health Board (“the Health Board”)failed to provide appropriate care and treatment during Ms B’s pregnancy and labour which resulted in the loss of their son, E. In particular, Ms B and Mr C complained that the Health Board failed to …
PSOW (Public Services Om…
Health
Upheld
Dec 2021
PSOW-201900726 — Betsi Cadwaladr University Health Board
Mr X’s complaint to the Ombudsman was in relation to a number of matters concerning his late mother, Mrs Y. Mrs Y’s care and complaint handling Mr X complained about aspects of his late mother, Mrs Y’s, care while she was an inpatient at the Hergest Unit between July and …
PSOW (Public Services Om…
Health
Dec 2021
PSOW-202106700 — Cwm Taf Morgannwg University Health Board
Mrs A complained about the care and treatment provided to her late husband by the Health Board. The Ombudsman found that, following its initial complaint response, the Health Board held a meeting with Mrs A in December 2021 and had agreed to further investigate her concerns. The Health Board made …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202006430 — Betsi Cadwaladr University Health Board
Mr X’s GP referred him to Ysbyty Glan Clwyd on 29 November 2019 and 26 February 2020 on an urgent basis with pilonidal sinus symptoms. Mr X attended the Hospital’s ED on 22 June, a MRI scan was requested, but Mr X left before he was discharged. Mr X attended …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2022
PSOW-202004139 — Hywel Dda University Health Board
Mr A complained about the treatment that he had received from Hywel Dda University Health Board. He said that the Health Board had failed to diagnose an avulsion (pulling or tearing away) injury to a tendon (strong tissue that connects a muscle to a bone) in his left ring finger …
PSOW (Public Services Om…
Health
Upheld
Mar 2022
PSOW-202004499 — Aneurin Bevan University Health Board
Mr D complained that the care and treatment that his late mother in law, Mrs M, received following her transfer from the Royal Gwent Hospital (“the First Hospital”) to Ystrad Fawr Community Hospital (“the Second Hospital”) contributed to her sudden death some 2 days later from Hospital Acquired Pneumonia (“HAP”). …
PSOW (Public Services Om…
Health
Upheld
Mar 2022
PSOW-202000167 — Aneurin Bevan University Health Board
Mr L complained about the care provided to his late mother, Mrs M, when she was an inpatient in November 2019. Specifically, Mr L complained that the Health Board failed to monitor and treat Mrs M’s breathlessness properly; failed to provide her with adequate support to use the toilet; did …
PSOW (Public Services Om…
Health
Upheld
Mar 2022
PSOW-202005555 — Swansea Bay University Health Board
Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with a sarcoma (a rare type …
PSOW (Public Services Om…
Health
Upheld
Jun 2022
PSOW-202103161 — Hywel Dda University Health Board
Mrs G complained about the care and treatment provided to her late husband Mr G, by Hywel Dda University Health Board between September 2019 and March 2020 following a shoulder operation. Mrs G was concerned that: a) The Health Board failed to adequately investigate and treat Mr G’s ongoing shoulder …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202105722 — Betsi Cadwaladr University Health Board
Mrs Y complained about her mother, Mrs A’s, care, and treatment by the Health Board during Mrs A’s admission to Wrexham Maelor Hospital between 22 July and 4 August 2020. She complained that the Health Board transferred Mrs A to a COVID 19 designated ward for treatment and treated Mrs …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202301555 — Hywel Dda University Health Board
Mr G complained about the care provided to his father, Mr M. Mr G said that Hywel Dda University Health Board (“the Health Board”) failed to diagnose Mr M’s lung cancer promptly, and that it discharged Mr M inappropriately and without palliative support in November 2021. The Ombudsman found that …
PSOW (Public Services Om…
Health
Not Upheld
Jan 2024
PSOW-202208381 — Hywel Dda University Health Board
Mrs A complained about the care and treatment Hywel Dda University Health Board provided to her late husband, Mr A. Specifically she complained that the Health Board failed to identify an abdominal aortic aneurysm on a scan that her late husband underwent, and that this failure meant that he failed …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202207425 — Swansea Bay University Health Board
Mrs Z complained about the care and treatment that she had received from Swansea Bay University Health Board. The investigation considered whether there was a failure to assess Mrs Z’s injury properly when she attended hospital, which led to a failure to diagnose a hamstring tear, and if this led …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202203822 — Hywel Dda University Health Board
Mrs A complained about the care and treatment provided to her husband, Mr A, by Hywel Dda University Health Board (“the Health Board”), following his attendance to Glangwilli General Hospital (“the Hospital”) in August 2021. Specifically, she queried whether the treatment he received for gallstones reached a reasonable standard. She …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202203786 — Cardiff and Vale University Health Board
Mrs A’s complaint related to the care and treatment that she received from Cardiff and Vale University Health Board (“the Health Board”). Specifically, Mrs A complained that the Health Board had failed to diagnose her with a vesico-vaginal fistula (an abnormal opening between the bladder and vagina) in a timely …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202203509 — Swansea Bay University Health Board
The investigation found that Mrs A was not fully aware of how unwell her husband was, and the paramedics and clinicians ought to have known this and further consideration should have been given to involving Mrs A in her husband’s care. Mrs A was not informed about the do not …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202203229 — Betsi Cadwaladr University Health Board
The Ombudsman investigated Mr A’s complaint about the care he received in September 2021 after he presented at an Emergency Department (“ED”) with a severe headache. The investigation considered whether the following were clinically appropriate: • the diagnosis, which resulted in a lumbar puncture (a thin needle inserted into the …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202202959 — Swansea Bay University Health Board
Mr A complained about the care and treatment provided by Swansea Bay University Health Board (“the Health Board”) after he accidentally cut his left index finger with a utility knife. In particular, he said that the Health Board failed to prescribe appropriate antibiotics to prevent an infection at the time …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202201990 — Cardiff and Vale University Health Board
Ms C complained about whether the treatment she received at the University Hospital Llandough on 6 July 2021 was appropriate. Ms C said that she had been given an incorrect diagnosis and prognosis which led her to close her business and suffer much mental anguish. The investigation found that the …
PSOW (Public Services Om…
Health
Not Upheld
Jan 2024
PSOW-202201816 — Cwm Taf Morgannwg University Health Board
Ms C complained about the care and treatment her late father, Mr A, received when he was admitted to hospital on 2 occasions between 10 December 2021 and 14 January 2022. We considered whether communication with Mr A’s family, including around visiting restrictions, during his time in hospital, was sufficient …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202104268 — Cardiff and Vale University Health Board
Mrs A complained that there was an unreasonable delay by the Health Board in securing appropriate clinical treatment for her daughter, B, between March 2021 – when she first attended University Hospital of Wales with a jaw dislocation – and October 2021 when she was referred to a specialist hospital …
PSOW (Public Services Om…
Health
Upheld
Feb 2024
PSOW-202108316 — Hywel Dda University Health Board
Miss A complained about the care provided to her father, Mr B, by the Health Board between January and July 2020. The investigation considered whether the Health Board failed to diagnose Mr B’s cauda equina syndrome (“CES” – a rare and severe type of spinal stenosis – where the bundle …
PSOW (Public Services Om…
Health
Upheld
Feb 2024
PSOW-202300527 — Betsi Cadwaladr University Health Board
Ms D complained about the care and treatment her sister, Ms A, received from Wrexham Maelor Hospital (“the Hospital”) in July 2022 . Ms A had several medical conditions, including epilepsy (a condition which causes seizures), cerebral palsy (a condition that affects movement and co-ordination) and learning disabilities. She lived …
PSOW (Public Services Om…
Health
Jun 2024
PSOW-202304528 — Cardiff and Vale University Health Board
The Ombudsman found that overall, the care and treatment provided to Mr B at the First Hospital between 3 and 8 May 2022 was appropriate. The Ombudsman did not uphold complaints a) to c). The diagnosis and management of Mr B’s bowel obstruction was also considered to be reasonable and …
PSOW (Public Services Om…
Health
Upheld
Jun 2024
PSOW-202204536 — Hywel Dda University Health Board
Mr and Mrs A complained that the Health Board’s treatment and care of their daughter, Ms B, who had a learning disability (“LD”), fell below a reasonable standard. Specifically, Mr and Mrs A complained that Ms B’s diagnosis and treatment were delayed, that the nursing care she received was not …
PSOW (Public Services Om…
Health
Upheld
Oct 2024
PSOW-202203509 — Swansea Bay University Health Board
The investigation found that Mrs A was not fully aware of how unwell her husband was, and the paramedics and clinicians ought to have known this and further consideration should have been given to involving Mrs A in her husband’s care. Mrs A was not informed about the do not …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
21-003-888 — London Borough of Ealing
Summary: Mrs B has complained that the Council did not properly consider her difficulty walking when refusing a Blue Badge. The Ombudsman has found fault in that the Council did not take all relevant factors into account when conducting a telephone assessment and review. However, the Council has since carried …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
25-001-947a — Bupa Care Homes (CFH Care) Limited (25 001 …
Summary: Mrs X complained about many issues relating to the Care Provider’s management of her late parents (Mr and Mrs Y’s) care in one of its residential care homes. Some of the complaints are late. An insurance or court claim for loss or damage to valuables would be a more …
LGO (Local Government & …
Health
Nov 2025
25-002-679 — Wigan Metropolitan Borough Council
Summary: Mr X complains about the Council’s handling of Mr Y’s discharge from hospital. Mr X complains the Council did not properly complete Mr Y’s capacity assessment and arranged an unsuitable discharge care plan. Mr X says this put Mr Y at risk and impacted his physical health. We find …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
202402369 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board failed to reasonably communicate with their family when their parent (A) was admitted to hospital. A was taken to A&E following a fall at home. A was moved to a ward following an x-ray and medical review showing that A had broken their hip. A …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202310183 — Lanarkshire NHS Board
C complained about the standard of care provided by the board to their parent (A). A had a complex medical history including depression for which they were on three types of anti-depressants. This was noted when A was admitted to hospital but staff failed to provide A with their prescribed …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202310085 — Greater Glasgow and Clyde NHS Board - Acute …
C complained about the care and treatment provided to their spouse (A) when they attended A&E. A had fallen from a height and injured their shoulder. A was x-rayed and diagnosed with a soft tissue injury to the shoulder and a minor head injury. A was discharged home and advised …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202309997 — Grampian NHS Board
C complained about the care and treatment provided to their parent (A) during an admission to hospital. C complained that the board had failed to manage placement of a nasogastric tube (NG) correctly and did not act timeously on signs of a complication. C said that the board failed to …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202308046 — Dumfries and Galloway NHS Board
C complained about the care and treatment provided to their late spouse (A). C complained that A had an infected toe which remained unresolved despite undergoing several months of treatment. A was diagnosed with oesophageal cancer but was unable to start chemotherapy treatment because of the ongoing infection. C said …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2025
202307773 — Lanarkshire NHS Board
C’s elderly spouse (A) spent approximately ten weeks in hospital. While in hospital, A fell on two occasions. C complained about the medical, nursing and physiotherapy care and treatment provided by the board. We took independent advice from a consultant geriatrician (specialist in medicine of the elderly). We found that …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2025