Incident commander communication training
Lack of specific training for incident commanders on the critical requirements of communication with control rooms during emergencies.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
68 inquiry recs
6 PFD reports
1 HSSIB rec
1 CQC action
3 PPO recs
6 IOPC recs
2 IMB recs
2 Scottish FAIs
1 Article 2 learning point
3 detention investigation recs
4 DHR recs
6 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(68)— showing 50 strongest matches
93 — Post-accident de-briefing procedures
Recommendation: Post-accident de-briefing procedures should be reviewed to ensure that combined de-briefings are held between all involved Railway Industry and Emergency Services groups (paras 2.25, 16.28).
Unknown
90 — Liaison with hospital and casualty gathering areas
Recommendation: More effective means of liaising with hospital and casualty gathering areas should be considered (para 2.14).
Unknown
86 — Upgrade the role of Rail Incident Officer
Recommendation: Steps should be taken to upgrade the role of Rail Incident Officer and to ensure that the person so designated has sufficient authority and standing for the task in hand, bearing in mind the tensions that can develop in the …
Unknown
P1-12 — Train control room operators on incident commander communications
Recommendation: All CROs of Assistant Operations Manager rank and above receive training directed to the specific requirements of communication with the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-11 — Train incident commanders on control room communications
Recommendation: All officers who may be expected to act as incident commanders (i.e. all those above the rank of Crew Manager) receive training directed to the specific requirements of communication with the control room.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-10 — LFB review control room communications policy
Recommendation: The LFB review its policies on communications between the control room and the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
COVID-M1.10 — Independent Statutory Resilience Body
Recommendation: The UK government should, in consultation with the devolved administrations, create a statutory independent body for whole-system civil emergency preparedness and resilience. The new body should be given responsibility for: providing independent, strategic advice to the UK government and devolved …
Gov response: Since the pandemic, significant strategic and material changes have been made to the way in which the UK and devolved governments handle crises. Considerable progress has been made against the longer-term programme to build a …
Response Unclear
COVID-M1.1 — Simplify Emergency Preparedness Structures
Recommendation: The governments of the UK, Scotland, Wales and Northern Ireland should each simplify and reduce the number of structures with responsibility for preparing for and building resilience to whole-system civil emergencies. The core structures should be: a single Cabinet-level or …
Gov response: The government agrees that clear governance is needed to build resilience across the UK. As per the Inquiry’s recommendation, in July 2024, the Prime Minister established a single ministerial committee to oversee action to build …
Accepted
POH-19 — Publish restorative justice programme by 31 October 2025
Recommendation: By 31 October 2025, the Department, Fujitsu and the Post Office shall publish, either separately or together, a report outlining any agreed programme of restorative justice and/or any actions taken by that date to produce such a programme. For the …
Gov response: DBT, the Post Office and Fujitsu have jointly embarked on a restorative justice project for postmasters, facilitated by the Restorative Justice Council. All 3 parties are committed to the programme being postmaster-led. The first phase …
Accepted
MAI-167 — Clarify Casualty Collection Point terminology
Recommendation: The terms Casualty Collection Point and Casualty Clearing Station are capable of being confused, one for the other, particularly in circumstances of stress. That happened on the night of the Attack. The National Ambulance Resilience Unit should consider whether different …
Gov response: Accepted in full
Accepted
MAI-158 — Guidance on commander location during incidents
Recommendation: The Home Office, the National Ambulance Resilience Unit, the College of Policing and the Fire Service College should develop guidance as to where commanders should locate during a spontaneous Major Incident. Steps should be taken to ensure that a consistent …
Gov response: Accepted in full
Accepted
MAI-151 — App for commander contact details
Recommendation: The Home Office, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should consider together whether an app giving ready access to the contact details for all on-duty and on-call commanders is feasible and, if …
Gov response: Accepted in full
Accepted
MAI-150 — Police notice of significant pre-planned events
Recommendation: The Home Office, the College of Policing and His Majesty's Inspectorate of Constabulary and Fire and Rescue Services should develop a system for ensuring that the duty command structure in each police service has notice of any significant pre-planned event, …
Gov response: Accepted in full
Accepted
MAI-140 — Review Major Incident plans for interoperability
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit, individual police services and JESIP should review what changes need to be made to …
Gov response: Accepted in full
Accepted
MAI-138 — Common terminology for non-Plato hazardous zones
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should ensure that all emergency services use common terminology to describe the …
Gov response: Accepted in full
Accepted
MAI-137 — Common terminology for Operation Plato zones
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should ensure that all emergency services use common terminology to describe the …
Gov response: Accepted in full
Accepted
MAI-136 — Awareness of specialist capabilities across services
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and all local resilience forums should take steps to ensure, whether through multi-agency training …
Gov response: Accepted in full
Accepted
MAI-134 — Fire service notice of significant pre-planned events
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, and the Fire Service College should develop a system for ensuring that the duty command structure in each fire and rescue service has notice of any significant …
Gov response: Accepted in full
Accepted
MAI-131 — Force Duty Officer comprehensive training course
Recommendation: The Home Office, the College of Policing and Counter Terrorism Policing Headquarters should ensure that all police officers to be appointed to the role of Force Duty Officer or Force Incident Manager attend a comprehensive training course dedicated to Operation …
Gov response: Accepted in full
Accepted
MAI-125 — Silver Commander training for designated officers
Recommendation: The Home Office and College of Policing should ensure that any police officer whose position carries with it the expectation that they will assume a Tactical/Silver Commander role in the event of a spontaneous Major Incident (e.g. Night Silver in …
Gov response: Accepted in full
Accepted
MAI-122 — Maintain radio communications during Major Incidents
Recommendation: The emergency services should prepare, train and exercise for how they will maintain effective radio communications between emergency responders on the ground, commanders and control rooms, during the response to a Major Incident.
Gov response: Accepted in full
Accepted
MAI-79 — Train NWAS commanders on command relief procedures
Recommendation: North West Ambulance Service should train its Operational Commanders on the appropriate practice for relieving another of command and being relieved of command.
Gov response: Accepted in full
Accepted
MAI-34 — Review GMFRS information sharing during incidents
Recommendation: Greater Manchester Fire and Rescue Service should review its guidance and policies on how it receives and passes on information during a Major Incident. It is important that, for any update given, it is established when the last time the …
Gov response: Accepted in full
Accepted
MAI-32 — Train GMFRS commanders in operational discretion
Recommendation: Greater Manchester Fire and Rescue Service should ensure that its commanders are adequately trained in the use of operational discretion.
Gov response: Accepted in full
Accepted
MAI-30 — Nationally accredited Force Duty Officer training
Recommendation: Given the broad command responsibilities that the Force Duty Officer or Force Incident Manager will have in the early stages of the response to a Major Incident, the Home Office and the College of Policing should develop nationally accredited training …
Gov response: Accepted in full
Accepted
MAI-21 — Firearms officer training on Operation Plato
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should ensure that all firearms officers, including firearms commanders, receive adequate training in Operation Plato, including in what such a declaration means and the demands it will place upon them. This …
Gov response: Accepted in full
Accepted
MAI-13 — Train BTP Sergeants in Bronze Commander role
Recommendation: British Transport Police should ensure that all its Sergeants are trained in what is required of a Bronze Commander in the event of a Major Incident. This will help to make sure that the first Sergeant on scene can undertake …
Gov response: Accepted in full
Accepted
MAI-12 — Train BTP Inspectors as Bronze Commanders
Recommendation: British Transport Police should ensure that all its Inspectors are trained to undertake the Bronze Commander role in the event of a Major Incident.
Gov response: Accepted in full
Accepted
MAI-4 — Appoint control room intelligence collators (Fire)
Recommendation: All fire and rescue services should consider appointing a person within their control rooms who, in the event of a Major Incident, has the sole role of gathering and collating all available information and intelligence, and sharing it internally and …
Gov response: Accepted in full
Accepted
MAI-2 — Appoint control room intelligence collators (Ambulance)
Recommendation: All ambulance service trusts should consider appointing a person within their control rooms who, in the event of a Major Incident, has the sole role of gathering and collating all available information and intelligence, and sharing it internally and externally …
Gov response: Accepted in full
Accepted
SP7 — Second Force Incident Manager support
Recommendation: All police forces that have not implemented a model providing immediate and direct support to Force Incident Managers, ideally through a second Force Incident Manager, should consider adopting such arrangements to strengthen decision‑making during critical incidents.
Gov response: The first duty of the government is to keep citizens safe and the country secure, and the Police play a fundamental role in doing so. The Chair makes several recommendations to policing bodies, in Chapter …
Accepted
FENN-23 — Review emergency services information exchange and appoint LFB liaison officers
Recommendation: The emergency services shall review the exchange of information between themselves and London Underground during an incident, both at their controls and at the site. The London Fire Brigade should send an officer to attend at London Underground HQ as …
Unknown
HIDD-82 — BR to review and test communication systems with emergency services weekly
Recommendation: BR shall review its communication systems with the emergency services to ensure that efficient methods exist to provide and disseminate early information requiring immediate action. In the course of the review BR shall look particularly at communication between signal boxes …
Unknown
HIDD-81 — BR to equip signal boxes with direct lines and emergency dialling systems
Recommendation: BR shall complete its programme of equipping major signal boxes with direct lines to the appropriate electrical control and equipping other signal boxes with priority emergency dialling systems. Those direct lines and emergency dialling systems shall be logged and tested …
Unknown
HIDD-76 — Require BR and emergency services to maintain joint planning with table-top exercises
Recommendation: In the exercise of command and control at accident sites BR and the emergency services shall maintain their policy of joint planning supported by table-top exercises.
Unknown
P1-44 — Investigate LFB-MPS-LAS system compatibility
Recommendation: Steps be taken to investigate the compatibility of the LFB systems with those of the MPS and the LAS with a view to enabling all three emergency services' systems to read each other's messages.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-43 — Use METHANE messages for Major Incidents
Recommendation: A “METHANE” message should be sent as soon as possible by the emergency service declaring a Major Incident.
Gov response: The Phase 1 report includes a series of recommendations designed to improve the communication arrangements between the three emergency services, their respective control rooms and the incident ground. The Home Office is committed to working …
Noted
P1-42 — Designate single point of contact in control rooms
Recommendation: A single point of contact should be designated within each control room to facilitate such communication.
Gov response: The Phase 1 report includes a series of recommendations designed to improve the communication arrangements between the three emergency services, their respective control rooms and the incident ground. The Home Office is committed to working …
Noted
P1-41 — Establish inter-service control room communications
Recommendation: On the declaration of a Major Incident clear lines of communication must be established as soon as possible between the control rooms of the individual emergency services.
Gov response: The Phase 1 report includes a series of recommendations designed to improve the communication arrangements between the three emergency services, their respective control rooms and the incident ground. The Home Office is committed to working …
Noted
P1-40 — Communicate Major Incident declarations to all responders
Recommendation: Each emergency service must communicate the declaration of a Major Incident to all other Category 1 Responders as soon as possible.
Gov response: The Phase 1 report includes a series of recommendations designed to improve the communication arrangements between the three emergency services, their respective control rooms and the incident ground. The Home Office is committed to working …
Noted
P1-25 — Investigate modern control room to bridgehead communications
Recommendation: The LFB investigate the use of modern communication techniques to provide a direct line of communication between the control room and the bridgehead, allowing information to be transmitted directly between the control room and the bridgehead and providing an integrated …
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-24 — Direct control room to incident commander communications
Recommendation: The LFB develop a communication system to enable direct communication between the control room and the incident commander and improve the means of communication between the incident commander and the bridgehead.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
P1-13 — Dedicated control room to incident commander link
Recommendation: A dedicated communication link be provided between the senior officer in the control room and the incident commander.
Gov response: The government accepted in principle all the Phase 1 recommendations directed at central government. The Housing Secretary Robert Jenrick presented the formal response to Parliament on 21 January 2020, committing to swift and decisive action …
Accepted
75 — Specific matters the analysis must cover
Recommendation: In particular the analysis should specify:- (i) The formal command structure for the control of an emergency affecting the installation; (ii) The likely availability and capacity of helicopters, whether in-field or otherwise, for the evacuation of personnel; (iii) The types, …
Unknown
SP9 — NWAS Major Incident declaration procedures
Recommendation: North West Ambulance Service should review its procedures for declaring a Major Incident or Major Incident (Standby) to ensure clarity in how declarations are made and how they are communicated internally and to other emergency services.
Gov response: DHSC and NHS England support the issues that the recommendations for the North West Ambulance Service (NWAS) are directed towards. However, while NHS England considers local review of procedures and terminology to be important and …
Accepted
FENN-111 — Ensure British Transport Police and Fire Brigade radio compatibility in underground stations.
Recommendation: The radio equipment in underground stations for the British Transport Police must be made compatible with that used by the London Fire Brigade.
Unknown
FENN-30 — Review LFB instructions and training for command and control
Recommendation: The London Fire Brigade shall review its instructions and training arrangements for command and control.
Unknown
FENN-26 — Review LFB command handover procedures during major incidents
Recommendation: The London Fire Brigade shall review its procedures and criteria for handing over and assuming command during major incidents.
Unknown
HIDD-84 — Rectify high-priority deficiencies in railway communication systems and signal-post telephones
Recommendation: BR shall ensure that efficient arrangements exist to rectify as a matter of high priority any deficiencies in the communication systems involved in recommendations 81 and 82 and in signal-post telephones.
Unknown
HIDD-78 — Require each service to maintain up-to-date staff lists within inner cordon
Recommendation: Each service shall additionally maintain on site an up-to-date list of staff within the inner cordon in case evacuation is necessary.
Unknown
Prevention of Future Deaths reports(6)
Mark Lilliott
Concerns: The coroner noted a delay in prison officers accessing a radio to call for emergency assistance, due to officers leaving the cell and difficulty communicating across noisy prison levels. Although this did not affect the outcome in this specific case, such delays could be critical in future emergencies.
Overdue
Glenda Logsdail
Concerns: The coroner identified insufficient confirmatory checks for endotracheal tube placement and a diagnostic fixation that inhibited other staff. Concerns included an inhibitory hierarchical structure, team malfunction during the emergency, and variable ventilator display configurations.
Response (Milton Keynes University Hospital NHS Foundation Trust): • The Trust has managed individuals involved in the incident and has put in place appropriate supervision and support. • The Trust has shared 'no trace, wrong place' resources, implemented … (AI summary)
Response (Royal College of Anaesthetists): • The Royal College of Anaesthetists will develop resources for multidisciplinary team training on unrecognised oesophageal intubation. • It will work with the Association of Anaesthetic and Respiratory Device Suppliers … (AI summary)
Response (Department of Health Social Care): • Health Education England (HEE) is implementing a specialty training recovery project to enhance simulation-based training for multi-professional teams. • HEE is developing standards in simulation-based education and training, including … (AI summary)
Response (Royal College of Anaesthetists): • The Royal College of Anaesthetists (RCoA) launched a coordinated campaign to disseminate key learning points from the case, utilising a dedicated webpage, educational talks, and articles in professional publications. … (AI summary)
Responded
Thomas Moffett
Concerns: The coroner identified inadequate communication between prison healthcare personnel and both the prison control room and ambulance control during medical emergencies. This recurring issue in Lancashire prisons suggests a potential national problem.
Response (Spectrum): • Spectrum CIC revised the Emergency Response Standard Operating Procedure at HMP Preston to include a second healthcare staff member for emergencies. • The new system was successfully trialled, and … (AI summary)
Overdue
Azroy Dawes-Clarke
Concerns: The coroner noted confused communication and an absence of a clear command structure among prison staff, healthcare professionals, and paramedics during a medical emergency. There remained a lack of clarity on roles and responsibilities, and how such situations would be managed in the future.
Response (Department of Health and Social Care): • Officials made enquiries with NHS England regarding the issues highlighted in the report. • The Department confirmed that HM Prison and Probation Service holds primacy for leadership, command, and … (AI summary)
Overdue
Alexander Lewis
Concerns: The coroner noted no opportunity for pursuing drivers to communicate dynamic risk assessments to control centres and that drivers had too many tasks, leading to missed critical information. It was also stated that pursuits would be safer with a double-manned crew.
Response (Department of Transport): • The Department of Transport stated there are no specific statutory regulations for the minimum distance single yellow lines must be situated from a junction. • The Department noted that … (AI summary)
Response (Minister of State for Policing and Crime): • The Government works with the National Police Chiefs’ Council and the College of Policing to ensure police driver training meets high and consistent standards. • The College of Policing … (AI summary)
Response (South Wales Police): • South Wales Police delivers pursuit training that equips single-crewed officers to manage dynamic risk assessments and communicate effectively. • The force maintains robust post-pursuit review processes to examine tactics … (AI summary)
Responded
Saffron Cole-Nottage
Response (East of England Ambulance Service NHS Trust): The Trust has approved a new protocol (ESOP146) for Fire and Rescue Service engagement, shared FRS capability videos, and allocated protected time for call handlers. They have engaged with the … (AI summary)
Response (NHS England): NHS England's Emergency Capability Unit (ECU) undertook an SBAR review in response to the report, identifying an absence of specific training for EOC staff relating to water incidents. The ECU … (AI summary)
Response (JESIP): JESIP has launched a revised Interoperability Leadership Training Course (JILT) and commissioned videos to promote the use of JESIP methodology and ETHANE messaging in all multi-agency incidents. They are also … (AI summary)
Responded
CQC inspection actions(1)
PPO death in custody recommendations(3)
The Governor
The Governor should remind all staff that they should use the appropriate emergency medical code to communicate the nature of the emergency efficiently.
The Governor of Isle of Man Prison
The Governor should introduce a clear protocol to staff for effectively communicating a medical emergency.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that accurate information is given from the scene of an emergency incident to staff in the control room about the condition of a prisoner.
IOPC learning recommendations(6)
Recommendations - West Midlands Police, July 2020
The IOPC recommends that West Midlands Police ensure the Force Control Room be formally notified and a log be created, with key details e.g. address, in advance of any firearms operations. Should additional resources or medical assistance be required, this …
National recommendations - National Police Chiefs Council, September 2020
The IOPC recommends that national guidance be amended/updated to state that prior to firearms operations, where timing allows (e.g. pre-planned operations) and where doing so would not present any issues regarding safety and security, an incident log should be created …
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review measures to be taken by control room staff in instances where emergency calls to third parties such as West Midlands Ambulance Service (WMAS) are placed on hold for a significant …
Woman killed after man drives wrong way on A13 – Essex Police, …
The IOPC recommends that Essex Police review how they can assist single crewed dispatchers when a cross border pursuit occurs. This follows an IOPC investigation which found that as the dispatcher was single crewed, they were not able to monitor …
Recommendations - Greater Manchester Police, May 2024
The IOPC recommends that Greater Manchester Police reviews their guidance on the use of force radio channels whilst a pursuit is ongoing, with the aim of reducing non-critical and non-time sensitive radio traffic from unrelated incidents whilst pursuits are underway, …
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) should include relevant content on the MPS intranet around the Joint Emergency Services Interoperability Principles (JESIP), promoting the value of JESIP to recruits and providing links to the relevant material. This …
IMB individual recommendations(2)
Hull (2024)
The Board would suggest that you reinforce and actively monitor the required protocols for how and when prison officers should proactively communicate with the Board for events such as serious incidents and segregation reviews.
Governor / Director
Dovegate (2021)
Continue to encourage staff to make proper use of the BWCs which are now available and worn by frontline staff. Staff should be reminded that their value as de-escalation and evidential tools is only useful if they are turned on. This is essential for in-cell interaction where no other CCTV source is available.
Governor / Director
Scottish Fatal Accident Inquiries(2)
Amanda Duncan
The Fire Brigade should review the standard command instructions and reinforce training especially with BA teams so that those who give and those who receive instructions have no scope in the future for such misunderstanding. In any event, and for the avoidance of doubt henceforth, it is my very clear opinion that firefighters should be required on an annual basis …
Mar 1999
Police Constable Lewis Fulton
I make no specific recommendation in this regard but it does appear to me that the system of communication with dog handlers is one which ought to be re-examined.
Jan 2003
Detention investigations(3)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 3
those likely to represent the Immigration Service in the Gold suite at Prison Service headquarters should attend a number of Prison Service incidents to familiarise themselves with general processes and practices.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 2
IND and the Prison Service give further consideration to contingency arrangements to ensure greater clarity and proper lines of accountability, and which, ideally, give IND ultimate authority and responsibility for the management of incidents. Failing this, I recommend a small cadre of potential Gold Commanders be prepared/trained specifically for handling …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 1
GSL reviews deployment of staff to incidents and the use of ‘talk through’ mode on the radio allowing officers to self deploy.
Immigration Detention
Independent reviews(4)
Kerslake Review — Rec 27
Potential Strategic Coordinating Group Chairs should pursue a clear objective to undertake a Strategic Coordinating Group update briefing (physically or virtually) within two hours of the declaration of a major incident
Policing & Security
Accepted
Kerslake Review — Rec 22
The response to the Arena attack provided an extraordinary validation of the on-going work within the UK civil protection sector to embed the JESIP Interoperability Framework into practice. Where responders were able rapidly to co-locate, communicate and coordinate their activities, situational awareness was usefully shared, risks were jointly assessed, and …
Policing & Security
Accepted
Kerslake Review — Rec 12
The Chief Fire Officers’ Association, National Fire Chiefs’ Council and Greater Manchester Fire and Rescue Service should revise all policies, procedures and training for National Inter-Agency Liaison Officers and Incident Commanders to ensure that greater emphasis is placed on embedding multi-agency co-location, communication and coordination during major incidents into their …
Policing & Security
Accepted
Kerslake Review — Rec 1
Greater Manchester Resilience Forum members should investigate ways to increase their own personnel’s understandings of their partner agencies’ procedures and operational priorities during the first 30 minutes to one hour of a major incident
Policing & Security
Accepted
LGO / SPSO decisions(6)
201101523 — Lothian NHS Board
Mr C's son was an in-patient at a clinic. Mr C raised concerns about staff accusations that he and his partner made inappropriate and/or racial comments about or to nursing staff. Mr C claimed that when he challenged the accusations, staff refused to detail what comments had caused offence or …
SPSO (Scottish Public Se…
Health
Not Upheld
Nov 2011
201005329 — Greater Glasgow and Clyde NHS Board
Ms C, an advice worker, complained to us on behalf of Mrs A, about the board. She said that they had failed to respond appropriately to Mrs A's sudden drop in blood pressure following an operation on her eye under general anaesthetic. During the post-operative period of the eye operation, …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2011
201204853 — A Medical Practice in the Forth Valley NHS …
Mr C complained that his medical practice refused to update him on changes in his son (Master A)s medical file, about which his estranged wife had not told him. Mr C also complained that the practice had prevented him from transferring his son to an alternative practice in the area. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013
201204558 — Grampian NHS Board
Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2013
201204522 — Glasgow Housing Association Ltd
Mr C needed a lot of support with housing matters. He was asked to go to his local housing office about a rent matter and called in, expecting to see one of two officers he had dealt with before, but they had both retired. He was introduced to his new …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2013
201203006 — Orkney NHS Board
Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013
Domestic Homicide Reviews(4)
Herefordshire — recommendation 3
SBARD training will be delivered to the teams involved in this case and will also be made available to other Trust services in Herefordshire.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Sefton — recommendation 7
Incidents of concern such as critical incidents and high risk missing persons should be clearly defined and classified and an officer at inspector level (usually a CIM) or above should be identified as the person in charge of it. That individual’s details should be recorded on Storm and if responsibility …
Merseyside Police
Merseyside Police
Solihull — recommendation 4
West Midlands Police and West Midlands Ambulance Service Domestic Homicide Review leads or relevant organisational leads should jointly consider the learning from this Domestic Homicide Review relating to call handling and review practice and procedures where incidents require both services. • This should include ensuring that call assessors from either …
West Midlands Police | West Midlands …
West Midlands Police
Sefton — recommendation 9
Appropriate supervisors, particularly critical incident managers (CIM), should be provided with regular training updates regarding any effective practice and lessons learned from relevant reviews.
Merseyside Police
Merseyside Police