No open learning culture
Absence of a culture of openness, honesty, and learning from error within organisations, leading to failures in responding to concerns.
Source spread
Where this theme appears
This theme appears across 26 independent accountability sources, so the source mix matters as much as the headline total.
106 inquiry recs
294 PFD reports
411 committee recs
111 HSSIB recs
335 CQC actions
4 HMICFRS recs
3 ICIBI recs
29 PPO recs
6 IOPC recs
30 NAO recs
4 PHSO recs
72 IMB recs
11 IMB reports
5 Scottish FAIs
12 Article 2 learning points
1 detention investigation rec
582 DHR recs
5 LGO/SPSO decisions
5 CJINI reports
10 CQC enforcement actions
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(106)— showing 50 strongest matches
85 — Responses to the S&SD paper on accident investigation
Recommendation: Responses to the S&SD paper “The Future of Accident Investigation in the Railway Industry” should be taken into consideration in applying the foregoing Recommendations (para 15.29).
Unknown
76 — HMRI to decide what data passes to rail companies
Recommendation: HMRI should decide, irrespective of any ongoing criminal investigation, what data or information is to be passed on to rail companies for rapid action (para 15.24).
Unknown
75 — Standing contracts for railway experts
Recommendation: Standing contracts for the provision of consulting services by recognised railway experts should be amended to make provision for HMRI to require any appropriate individual to provide expert services for the immediate accident investigation, including the services of any appropriate …
Unknown
74 — A single definitive technical investigation
Recommendation: HMRI should ensure that a single, thorough and definitive technical investigation is carried out, to include the recording of all appropriate factual data, the collection of physical evidence from the scene of the accident and decisions as to handing the …
Unknown
73 — HMRI to control technical investigation of serious accidents
Recommendation: The technical investigation of serious rail accidents should be controlled by HMRI save in exceptional cases of suspected crime which is unconnected with the running of the railway (para 15.23).
Unknown
72 — Consultation on Group Standards
Recommendation: Consultation procedures and times involved in revision of Group Standards or the introduction of new Group Standards, should be reviewed by the Inquiry to be held into safety procedures (para 16.8).
Unknown
57 — Resolve inter-company research and development issues
Recommendation: Steps should be taken to put in place means to resolve inter-company issues relating to research and development at all levels. Specifically, the following issues must be addressed (paras 15.13, 16.21).
Unknown
55 — Data recorders on all trains
Recommendation: All trains should be fitted with data recorders. All data recorders should record speed, time/location, brake application and AWS cancellation, and should be simple and speedy to download (para 14.23).
Unknown
9 — Review of drivers' working hours
Recommendation: Current Rules governing drivers’ permitted daily and weekly working hours should be reviewed in the light of current research into human behaviour (para 5.9).
Unknown
6 — Encourage drivers to report faults
Recommendation: Drivers should be encouraged to report all actual or suspected faults, whether through formal fault reporting procedures or through CIRAS (paras 14.26, 16.4).
Unknown
3 — Simulators for driver training
Recommendation: Simulators should be introduced for driver training and for the observance of driver behaviour (para 16.3).
Unknown
2 — Evidence from CIRAS and on-train data recorders
Recommendation: Evidence should include that to be provided by CIRAS and from On-Train Data Recorders used to monitor driver behaviour. ASLEF in particular should give their full support to such an initiative (paras 14.23, 14.25, 15.15, 16.3).
Unknown
1 — Co-operate on research into driver behaviour
Recommendation: All parties in the rail industry should co-operate in the collection of evidence to support reliable research into human behaviour studies relating to driver performance. Railtrack should co-ordinate this work and TOCs incorporate the results into training programmes (paras 1.25, …
Unknown
21 — Resolve doubt in favour of disclosure
Recommendation: Where there is any doubt as to whether a matter is of a substantial nature, if it relates to patient care the doubt shall always be resolved in favour of disclosure.
Unknown
FP86 — Recommendation 86
Recommendation: COPFS should task identified staff with maintaining up-to-date knowledge of cases, at least in anglophone jurisdictions, in which fingerprint evidence has been disputed, and with liaising with an identified contact in SPSA in relation to any implications that the findings …
No response yet
FP85 — Recommendation 85
Recommendation: The SPSA should task identified staff with: (i) maintaining up-to-date knowledge of cases, at least in anglophone jurisdictions, in which fingerprint evidence has been disputed; and (ii) monitoring cases in which courts, inquiries or other investigating bodies have made significant …
No response yet
FP69 — Recommendation 69
Recommendation: The SPSA should consider whether their procedures require to be revised in the light of the findings of an investigation of an erroneous fingerprint identification or exclusion.
No response yet
FP67 — Recommendation 67
Recommendation: The SPSA should investigate all ‘erroneous’ fingerprint identifications or exclusions.
No response yet
FP4 — Recommendation 4
Recommendation: Differences of opinion between examiners should not be referred to as disputes.
No response yet
AFA-5 — Serious Adverse Incidents
Recommendation: We recommend that: • The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in each Trust. This involves ongoing feedback and backing for Trusts …
Gov response: will undertake a detailed and urgent review of the findings and recommendations
Response Unclear
AFA-2 — Organisational development and cultural reform
Recommendation: The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. …
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
R34 — Debriefing policies for aggressive behaviour and restraint
Recommendation: All HSCTs should develop two clear operational debriefing policies. The first should apply to both staff and people with learning disabilities and autistic people who are involved in, or affected by, aggressive behaviour. A separate debriefing after any restraint or …
No response yet
RHI-36 — Learning from Failures
Recommendation: The Northern Ireland Civil Service should develop a better process to learn from past failures, one that goes beyond the traditional method of revising and circulating internal guidance. Leaders within the Senior Civil Service must be more systematic, persistent and …
Gov response: These recommendations can be accepted in full. They have been partially addressed through: • the revision of the NICS Code of Ethics; • the GIAFIS review of whistleblowing; • the Leadership Development training for senior …
Accepted
RHI-32b — Civil Servants Raising Concerns
Recommendation: Civil servants should be encouraged not to feel in any way inhibited about disclosing possible or emerging problems, raising concerns, negative aspects or adverse criticisms of a project as necessary to ensure that decisions are properly informed.
Gov response: These recommendations can be accepted in full. They have been partially addressed through: • the revision of the NICS Code of Ethics; • the GIAFIS review of whistleblowing; • the Leadership Development training for senior …
Accepted
26 — Ensure Home Office staff presence and visibility in IRCs
Recommendation: The Home Office must ensure that its staff are regularly present and visible within each immigration removal centre.
Gov response: 6.8.3. The DET teams are being expanded, with further recruitment underway to support the Home Office’s commitment to improving the access of detained individuals to Home Office staff. DET staff are regularly present and visible …
Accepted, fully or in part (not specified)
MAI-155 — Obtain comprehensive accounts from commanders
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should take steps to ensure that all emergency services understand the importance of promptly obtaining comprehensive accounts from commanders as part of the …
Gov response: Accepted in full
Accepted
MAI-128 — National systems to record lessons from exercises
Recommendation: The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems to identify and record the lessons learned from all multi-agency exercises and ensure that change is implemented as …
Gov response: Accepted in full
Accepted
MAI-127 — Robust debrief systems for multi-agency exercises
Recommendation: The Home Office and the Department for Levelling Up, Housing and Communities should ensure that there exist robust national and local systems and sufficient resources to make sure that the debrief process following multi-agency exercises is effective to capture the …
Gov response: Accepted in full
Accepted
MAI-94 — Review firearms officer Post Incident Procedures delays
Recommendation: The College of Policing should assess whether delays in the provision of written accounts by some firearms officers involved in the response to the Attack were due to Post-Incident Procedures. If so, those procedures should be reviewed.
Gov response: Accepted in full
Accepted
MAI-62 — LRF oversight of lessons from exercises and incidents
Recommendation: Local resilience forums should establish procedures to ensure that they oversee the process of identifying the lessons to be learned from major exercises, or serious incidents, in their areas, and that they are responsible for overseeing the debriefing of those …
Gov response: Accepted in full
Accepted
MAI-51 — Address Showsec failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made by Showsec to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
Gov response: Accepted in full
Accepted
MAI-50 — Address Arena failings identified in Volume 1
Recommendation: Improvements, to the extent that they have not already been made, should be made at the Arena to address the failings identified in Volume 1. Specific consideration should be given to how to address my concerns in relation to complacency.
Gov response: Accepted in full
Accepted
MAI-26 — Review international practice on medics with firearms officers
Recommendation: Counter Terrorism Policing Headquarters should review the experience of other jurisdictions that embed medics with police firearms officers, such as Recherche, Assistance, Intervention, Dissuasion (RAID) in France, to understand how their systems operate and whether they ought to be replicated …
Gov response: Accepted in full
Accepted
MAI-18 — Address BTP systemic failings from Volume 1
Recommendation: BTP should address the systemic failings identified in Volume 1, so as to ensure that they are not repeated.
Gov response: Accepted in full
Accepted
23 — Databases to highlight trends in reported faults
Recommendation: Databases should be programmed to determine and highlight statistically significant trends in faults reported and to display such information to managers and maintenance staff (para 16.9).
Unknown
22 — Fault databases to log repeat faults
Recommendation: Fault data bases (including RAVERS) should ensure that repeat faults are logged and that a 28 day history of defects is available to managers and maintenance staff (para 16.9).
Unknown
40 — Public relations and press liaison
Recommendation: The out-dated aura of seclusion at Whittingham should be dispelled by positive public relations activity. A member of the administrative staff, with suitable qualities, should be given a special responsibility for liaison with the press so as to cultivate constructive …
Unknown
20 — Duty to disclose substantial matters
Recommendation: The duty of utmost good faith shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic.
Unknown
39 — Database of leaks, spills and ignitions
Recommendation: The regulatory body should be responsible for maintaining a database with regard to hydrocarbon leaks, spills and ignitions in the industry and for the benefit of the industry. The regulatory body should:- (i) discuss and agree with the industry the …
Unknown
30 — Protection of safety representatives
Recommendation: Safety representatives should be protected against victimisation by a provision similar to Sec 58(i)(b) of the Employment Protection (Consolidation) Act 1978 (para 21.86).
Unknown
28 — Workforce involvement part of the SMS
Recommendation: The operator’s procedures included in line management of operations which are aimed at involving the workforce in safety should form part of its SMS (para 21.56).
Unknown
27 — Workforce involvement in safety
Recommendation: The regulatory body, operators and contractors should support and encourage the involvement of the offshore workforce in safety. In particular, first line supervisors should involve their workforce teams in everyday safety (para 18.48).
Unknown
63 — Basic training on dealing with prisoners
Recommendation: That part of the basic training course for new prison officers which focuses on the development of their inter-personal skills should be reviewed in the light of this report and the lessons to be learned from Zahid’s murder. In particular, …
Unknown
48 — Governors acting on external report comments
Recommendation: Governors should ensure that any relevant comments or recommendations in external reports about their establishments which have implications for the safety of prisoners be brought to the attention of the workforce.
Unknown
16 — Parliamentary and Health Service Ombudsman
Recommendation: The functions of the National Guardian’s Office should be taken over by the Parliamentary and Health Service Ombudsman in England. The Ombudsman’s powers must be increased to include: a. investigating complaints that whistleblowing in the NHS has not been dealt …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor the …
Unknown
AFA-1 — Patient focus and complaints
Recommendation: The Inquiry recommends that the Trust and Department work together to ensure there is: • A specific programme of work to strengthen patient involvement, improve communication, and ensure patients and families are treated as partners in care. • Direct communication …
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
R2 — Coroners to send post mortem reports to consultants
Recommendation: We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984 …
Gov response: The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the …
Accepted in part
R67 — Independent review of systemic abuse conditions
Recommendation: Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An independent review of enabling conditions should be conducted separately from case-specific or PSNI investigations. This review must be …
No response yet
LADB-17 — Develop a blame-free culture for safety information communication in industry
Recommendation: The development of a culture within the industry in which information is communicated without fear of recrimination, and blame is attached only where this is justified, is commended (para 9.60).
Unknown
BRIS-107 — Create open, non-punitive NHS environment for reporting sentinel events
Recommendation: Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.
Unknown
Prevention of Future Deaths reports(294)— showing 50 strongest matches
Muniza Mehrban
Concerns: The coroner noted four deaths within three years at the Arndale Centre multi-storey car park where individuals intentionally jumped from a height.
Overdue
Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet
Concerns: The coroner noted that Neonatal Unit (NNU) staff might underestimate the risk of cardiac tamponade as a complication of TPN feeding. Concerns were also raised that NNUs may not be sharing best practices effectively to limit this complication across different units.
Overdue
Carol Ann Gibson
Concerns: The coroner highlighted concerns about 'alert fatigue' within a medical practice, where a doctor prescribed a drug despite an adverse reaction alert. The report notes potential issues with the alert system, clarity of alerts, and staff training.
Overdue
Stephanie Daniels
Concerns: The coroner identified significant errors in internal Serious Untoward Incident investigations, suggesting independent oversight is needed. Concerns were also raised about inadequate patient handover, particularly a lack of review of recent records for new patients.
Response (Manchester Mental Health NHS): • The Trust stated it would review its Serious Incident Requiring Investigation policy to consider engaging independent investigators and develop further guidance for investigators. • The Trust stated Matrons would … (AI summary)
Response (Manchester Clinical Commissioning Groups): • The Citywide Commissioning, Quality and Safeguarding Team developed a revised governance process, including a monthly Citywide Patient Safety Committee and representation at High Level Investigation Panels to review and … (AI summary)
Response (Department of Health): • The Secretary of State confirmed the concerns were sent to the National Trust Development Authority (NTDA). • The NTDA received an action plan from the Manchester Health and Social … (AI summary)
Responded
Martin McGlasson
Concerns: The coroner noted concerns regarding a widespread work method used in the industry and the need for risk assessments to be properly disseminated and explained to staff operating the process.
Response (DWF): • The company ceased the practice of storing staircases on their edges without restraint and installed a "TOAST RACK" support system. • It revised risk assessments and safe working procedures, … (AI summary)
Responded
Daniel Williams
Concerns: The coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.
Response: • All Inpatient staff received training packs and completed e-learning on 'Personalised Care Planning 2013 Record keeping and communication' in November. • The Trust developed and distributed guidance for checking … (AI summary)
Responded
John Davies
Concerns: The coroner noted that doctors undergoing General Medical Council investigations may experience adverse psychological effects that are unrecognised and unsupported. The report suggests considering communication tone, providing information on support agencies, and assessing for suicidal or self-harming behaviour.
Overdue
Agostino Costa
Concerns: The coroner noted confusion among staff regarding patient-specific falls risks and classification. Inadequate post-fall management knowledge, insufficient dissemination of root cause analysis findings, and non-mandatory falls training were also identified.
Overdue
Jackson Chadd
Concerns: The coroner identified a lack of effective supervision for paediatricians, particularly during out-of-hours, and insufficient independent consultant assessment for paediatric admissions. Concerns also included the ineffective application of national guidelines for fever in children under one year and a failure to act on a parent's concerns.
Response (Frimley Park Hospital): • The Trust appointed a new Emergency Department Paediatric Consultant and established a consultant responsible for Paediatric A&E. • The Trust implemented a policy requiring junior doctors to notify a … (AI summary)
Response (Royal College of Paediatrics Child Health): • The Royal College of Paediatrics and Child Health (RCPCH) commenced a review of its 'Facing the Future' standards, specifically reconsidering the frequency of consultant review for admitted children. • … (AI summary)
Overdue
Eric Matthews
Concerns: The coroner notes limited awareness, even in academic circles, of the risk of positional asphyxia associated with baby slings. There are also concerns that information about this risk has not been widely publicised to parents.
Response (University Hospital London NHS Trust): • The respondent investigated the feasibility of surveying 'cot deaths' in unusual scenarios such as slings and car seats. • The investigation determined that a survey was not feasible due … (AI summary)
Responded
Dana Baker
Concerns: The coroner noted a lack of knowledge and understanding between involved agencies, alongside inadequate communication. Individual Management Reviews (IMRs) were kept confidential and not shared, preventing agencies from commenting on areas of mutual concern.
Response (Safeguarding Children Board): • The Worcestershire Safeguarding Children Board (WSCB) stated that Individual Management Reviews (IMRs) have consistently been shared among agencies on Serious Case Review (SCR) panels. • The WSCB confirmed its … (AI summary)
Responded
Lloyd Butler
Concerns: The coroner noted a lack of professionalism and leadership in the custody suite, where inappropriate behaviour and banter were common. There was insufficient evidence of guidance or training for staff on acceptable conduct, indicating a need for cultural change within custody suites.
Response (West Midlands Police): • West Midlands Police (WMP) established a central department for custody management and reduced the number of custody suites. • WMP launched an internal 'Pride in our Police' campaign and … (AI summary)
Responded
Monique Whitbread
Concerns: The coroner identified that performing a gastric bypass on a patient with a hernia risked strangulation, leading to death. The report noted a need to disseminate nationally the surgeon's learning that a sleeve gastrectomy is a safer alternative for such patients.
Overdue
Thomas Taylor
Concerns: The coroner identified a lack of clear leadership and sufficient staffing on the ward. Additionally, there were no clear protocols for handling lost patient notes or for managing blood sugar monitoring, insulin administration, and escalation of care for hyperglycaemic patients.
Overdue
Anne Sandever
Concerns: The coroner noted a lack of nursing care, poor communication regarding Mrs. Sandever's diabetes, and that she was left without intravenous fluids despite renal failure. Additionally, the hospital's investigation into these issues was deemed insufficient.
Response: • The Trust introduced spot checks on wards and commenced a training programme for staff on recognising deteriorating patients and monitoring vital signs. • The Trust reviewed and updated its … (AI summary)
Responded
Janet Goodacre
Concerns: The coroner raised concerns about the Trust providing inaccurate and misleading investigation reports, which contained erroneous findings and incorrect root causes. There was also a failure to communicate the report's shortcomings or correct recognised errors before the inquest.
Response (University Hospitals of Leicester NHS Trust): • The Trust established a process for each Root Cause Analysis (RCA) investigation to have a named Chair who reviews the investigation's scope and ensures an adequate action plan is … (AI summary)
Responded
Phyllis Kerry
Concerns: The coroner noted a lack of clear guidelines for managing intra-cerebral bleeds in patients on Warfarin, an absence of clarity on specialty responsibility for reversal decisions, and insufficient communication of relevant guidelines to staff.
Response (Nottingham University Hospitals NHS Trust): • Discussions were held between relevant specialties to optimise the management of patients with intra-cerebral bleeds. • A new guideline has been prepared to provide more rapid intervention in anticoagulation … (AI summary)
Response (Nottingham University Hospitals NHS Trust2f): • A new guideline for the prompt and appropriate treatment of patients on Warfarin presenting with Intra Cranial Haemorrhage has been agreed and provided. • Heads of Service have been … (AI summary)
Responded
Agnes Hannan
Concerns: The coroner raised concerns regarding the lack of available hospital notes, poor communication among staff and with the patient's family, and inadequate patient monitoring. Further issues included consultant allocation and the process for initiating end-of-life care without sufficient family discussion.
Response (Tameside Hospital NHS Trust): • The Trust has implemented a new computer system for medical records and replaced the PARS observation system with the NEWS system, providing staff training for both. • A review … (AI summary)
Responded
Sandra Higham
Concerns: The coroner raised concerns about the difficulty in diagnosing atrial-oesophageal fistula, a rare but high-mortality risk of ablation procedures, due to its non-specific symptoms and a lack of awareness within the wider medical profession.
Response (BHRS): • BHRS will publish an article on the avoidance and recognition of atrial-oesophageal fistula in its winter newsletter for members. • BHRS will remind members to ensure atrial-oesophageal fistula is … (AI summary)
Response (UK Health Security Agency): • Public Health England stated it was unable to directly assist with the case. • It noted that the Department of Health would contact appropriate bodies, such as the British … (AI summary)
Response (Department of Health): • Officials contacted the Royal College of Surgeons, the Society for Cardiothoracic Surgery, and the British Cardiovascular Society regarding the concern. • Officials reported that the British Cardiovascular Society is … (AI summary)
Responded
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: The report notes the absence of national governance, a lead, and disease-specific benchmarking for autologous stem cell transplant. Unreleased international trial results prevent clinicians from knowing normal recovery times, potentially affecting optimal care for children.
Response (NHS England): • NHS England will issue a Specialised Services Circular to commissioning teams and providers, restating requirements for transplant providers. • NHS England will review service specifications for paediatric bone marrow … (AI summary)
Responded
Simon Alliston
Concerns: Concerns were identified regarding the discharge of a patient with a mental health history without formal handover, a recorded reason, or agreement from the community team, and that no formal Serious Incident Investigation followed.
Response (SEPT): • The Trust completed a Root Cause Analysis investigation into the patient's care. • The Trust reviewed its Serious Incident reporting process and decided that the default position is to … (AI summary)
Responded
Tanya Page
Concerns: The coroner noted a lack of communication between hospital wards regarding a patient's disclosure of a self-harm attempt, which appeared to be influenced by a concern about perceived blame between staff.
Overdue
Jane Robinson
Concerns: Basic patient observations were repeatedly unrecorded, with no senior review to detect shortfalls or written rationale for observation frequency. Additionally, the coroner noted no reporting system for professionals not meeting accepted standards.
Response (University Hospitals of Leicester NHS Trust): • Work has begun to introduce a competency assessment for Health Care Assistants, with completion expected by October 2015. • The Trust is implementing an electronic system for recording patient … (AI summary)
Responded
Thor Dalhaug
Concerns: The coroner raised concerns about the lack of supervision for an operating surgeon using an inappropriate delivery technique, along with deficiencies in contemporaneous record-keeping and candour. The Serious Untoward Incident investigation was also deemed inadequate, with no disciplinary action taken.
Response (United Lincolnshire Hospitals NHS Trust): • The Trust implemented new induction and supervision processes for junior doctors, including a week of supernumerary activity. • The Trust significantly reviewed and changed its Serious Incident investigation processes, … (AI summary)
Responded
Tamara Holboll
Concerns: The coroner identified a lack of precision in the trust's communication protocols, noting that staff lacked clear instructions on how to action identified communication needs effectively.
Response (Camden and Islington NHS Trust): • The trust amended its action plan template. • The trust revised its guidance for authors writing recommendations and action plans. • An action row was added to the action … (AI summary)
Responded
Doreen Wood
Concerns: The coroner noted concerns regarding Newgate Street surgery's INR monitoring system, specifically the reliance on healthcare assistants for clinical information when making dosing decisions. There was also a lack of an internal investigation to ensure all GPs learned from the events.
Overdue
Sheila Johnson
Concerns: The internal investigation report was insufficiently robust, failing to interview key witnesses or consider the clinical content of documentation, and contained factual inaccuracies. The Trust also lacked a system for urgent recall of patients discharged with potentially life-threatening conditions.
Response (Department of Health): • Departmental officials made enquiries with the Trust and shared the letter with the Care Quality Commission (CQC) and Monitor. • The CQC stated it would follow up on actions … (AI summary)
Response (Tameside Hospital NHS Trust): • The Trust has rewritten and implemented its policy for the management and investigation of serious incidents. • The Trust has provided root cause analysis and investigation training to over … (AI summary)
Responded
Wanda Stachurska
Concerns: The quality of mental health risk assessments was noted as diminished due to staff unawareness of policies and the routine use of untrained interpreters without guidance. The coroner also identified that a Serious Incident Review was not undertaken, delaying learning opportunities.
Response (Surrey and Borders Partnership NHS Trust): • The Trust ensured a shortcut to relevant policies was available on Psychiatric Liaison staff computers and made the translation services policy mandatory reading. • A local protocol was mandated … (AI summary)
Responded
Arthur Fry
Concerns: A communication breakdown meant an MRI scan was declined due to an uncommunicated consent requirement, potentially impacting the patient's care. Tighter controls are needed for requisitioning procedures like MRI and CT scans to avoid confusion and prevent failed procedures.
Response (University Hospitals North Midalnds NHS Trust): • Radiographers now document the name of the accompanying nurse and explicit instructions for the ward clinical team in the electronic CRIS system. • The Trust is in the process … (AI summary)
Responded
Isabella Drew
Concerns: The coroner identified a need for more explicit guidance on how local healthcare providers advise pregnant women about whooping cough vaccination, including audit and follow-up. Additionally, national guidance is needed for effective communication among antenatal care providers.
Response (NHS England): • Public Health England (PHE) introduced collection of pertussis vaccination uptake figures by ethnicity and extended enhanced surveillance to include maternal immunisation history and ethnicity. • PHE engaged with professional … (AI summary)
Responded
Simon Reynolds
Concerns: The coroner identified a lack of documented risk assessment upon service user admission to Mason Unit, and insufficient guidance and training for staff on setting observation levels, assessing and managing suicide/self-harm risk, and communicating that risk.
Overdue
Dean Joseph
Concerns: The coroner noted inconsistent understanding among officers regarding armed containment, a lack of guidance from trained hostage negotiators for untrained officers, and post-incident management procedures that eroded public confidence and hampered learning.
Response: • The Metropolitan Police Service (MPS) committed to enhancing training for firearms officers and commanders on armed containment types, communication, and the early deployment of trained negotiators. • The National … (AI summary)
Responded
William Tolen
Concerns: The coroner identified inadequate and fragmented record-keeping at the care home, impacting staff's ability to track care and confirm facts. Concerns included insufficient staff training for medical situations, delays in podiatry care, and the absence of a post-incident review.
Response (William Tolen): • Staff received further supervision and training in relation to documentation, and instructions were added regarding specific concerns. • Visiting professionals were advised that the home would not accept the … (AI summary)
Responded
Vasilis Ktorakis
Concerns: Concerns identified include registrars' clinical judgment errors, such as delayed medication and an incorrect decision on passive descent, and inadequate record-keeping. The hospital's incident investigation process also lacked robust systems for staff involvement and feedback, hindering learning.
Response: • Educational supervisors met with the registrars involved to discuss learning from the case. • A process was implemented for meetings at the start of maternity serious incident investigations to … (AI summary)
Responded
Carl Foot
Overdue
Angela Brealey
Concerns: The coroner identified concerns regarding the Trust's processes for handling and recording third-party information, particularly regarding confidentiality. There was also minimal multi-disciplinary team involvement in patient care and the serious incident review process did not pick up all concerns.
Response (South Staffordshire and Shropshire Healthcare NHS Trust): • The Trust has implemented a clear policy and process for receiving and storing third-party information in RiO. • The Serious Incident Review Process has been reviewed and amended, with … (AI summary)
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
Rubana Pathan
Concerns: The coroner noted insufficient dissemination of information to healthcare providers and implant manufacturers regarding how a specific toxin, linked to breast implant sepsis, can suppress signs of local inflammation.
Response (Homerton University Hospital NHS Trust): • The Trust requested a microbiologist to conduct a literature search on surgical site Staphylococcal Toxic Shock Syndrome. • The Trust shared detailed literature search findings and highlighted the need … (AI summary)
Overdue
Jonathan Lander
Concerns: The coroner noted the absence of a policy or procedure for following up individuals discharged from one service to another, observing that a previously agreed action plan for this had not been implemented since 2015.
Response (J Lander): • The Trust has implemented an agreed Substance Misuse Information Sharing Protocol with Swanswell Worcestershire Recovery Partnership. • The Trust has established an Embedded Lessons Database. • Action plans from … (AI summary)
Responded
Kathryn Bull
Concerns: The report describes a lack of understanding regarding the rare hyperammonaemia syndrome, an adverse consequence of gastric bypass surgery, and its symptoms.
Overdue
Patricia Steer
Concerns: Staff nurses lacked awareness of air embolization risks during uncapped and unclamped catheter changes, and there was a noted absence of literature or guidance on this specific procedural risk.
Response (NHS England): • The response identified existing guidance from the Royal College of Nursing and the Critical Care Network/National Nurse Leads concerning the risk of air embolization. • The issue was discussed … (AI summary)
Responded
Leilani Chute
Concerns: The coroner noted concerns regarding junior doctors performing a non-standard practice (manually pushing back the cervix) without consultant knowledge, and the inadequate process for obtaining informed consent from women in labour. These issues were not identified by the Trust's Root Cause Analysis.
Response (Western Sussex Hospital NHS Trust): • The Trust completed an audit of instrumental deliveries and amended local guidelines to state that manually pushing back the cervix is not acceptable practice. • Initial feedback was provided … (AI summary)
Responded
Stephen Bird
Concerns: The coroner noted incomplete, inconsistent, or conflicting patient records, consultations, clinical decisions, and discharge records. The hospital's draft Significant Clinical Incident Investigation report also contained factual assumptions that conflicted with documentary evidence, impacting the learning process.
Response (South Buckinghamshire Hospitals): • The hospital accepted that the standard of record keeping was poor and not in accordance with expected standards. • Monthly audits of consultant medical records were introduced, with non-compliance … (AI summary)
Responded
Dominic Travis
Concerns: The coroner identified a lack of specialist inpatient mental health provision for young adults in general adult psychiatric wards. Additionally, Pennine Care NHS Foundation Trust's internal investigation was inadequate, lacking independence and transparency, being conducted by directly involved staff.
Overdue
Andrew Machin
Concerns: The coroner noted limited support for Mr Machin during a lengthy disciplinary investigation and suspension. There was no internal investigation into his dismissal process, despite its proximity to his death.
Overdue
Shelia Stokes
Concerns: Concerns include administrative delays in patient follow-up and acting on alerts, alongside the lack of a clear protocol for obtaining custom-made grafts. The adequacy of the trust's internal investigation and the completeness of witness statements were also noted.
Response (Sherwood Forest Hospitals NHS Trust): • The Trust re-launched its DNA process in June 2016 to ensure consistent handling and clinician action, and conducts regular DNA audits. • Upgrades to the EMRAD systems are underway … (AI summary)
Response (Sherwood Forest Hospitals NHS Trust): • The Trust re-launched its DNA process in June 2016, implementing new procedures for managing missed appointments, including regular audits, and is planning to pilot scanning reconciliation slips. • Upgrades … (AI summary)
Response (Radiology Department): • The Radiology Department outlined its existing 'XXXX POLICY' for communicating critical, urgent, and significant unexpected radiological findings. • The 'XXXX POLICY' will be reviewed and modified to incorporate electronic … (AI summary)
Responded
Amanda Coulthard
Concerns: The coroner noted multiple avoidable deaths from misplaced nasogastric tubes, linked to staff non-compliance with policy, inadequate training, and insufficient audits. Concerns also included the Trust's failure to learn from prior incidents and implement national alerts.
Response: • The Department of Health highlighted the July 2016 Patient Safety Alert, which requires NHS Boards to assess and address compliance with safe nasogastric tube placement by April 2017. • … (AI summary)
Response (North Cumbria University Hospitals Trust): • The Trust provided a report summarising actions taken against the five specific actions in the Regulation 28 Notice. • The Trust committed to implementing additional identified actions over the … (AI summary)
Responded
Michael Parke
Concerns: The coroner noted recurring deaths from misplaced nasogastric tubes, citing staff non-adherence to policy, inadequate training, and the Trust's failure to address prior issues. Concerns were also raised about the lengthy and error-prone policy document.
Response: • NHS Improvement issued a Patient Safety Alert in July 2016, requiring NHS Trust Boards to assess and address compliance issues related to nasogastric tube placement by April 2017. • … (AI summary)
Response (North Cumbria University Hospitals Trust): • The Trust stated it had taken action against the five specific actions outlined in the Regulation 28 Notice. • The Trust indicated it would implement additional identified actions over … (AI summary)
Responded
Michelle Lawrence
Concerns: Concerns included the absence of independent investigation into deaths following release from private custody. The coroner also noted insufficient procedures for identifying and managing detainee concealment, inadequate CCTV monitoring, and character limits on the PNC system impacting risk assessment.
Overdue
Melanie Lowe
Concerns: The coroner noted the trust's action plan was very basic, lacked specific detail, and had an absence of supporting evidence, requiring a more rigorous plan.
Responded
Select committee recommendations(411)— showing 50 strongest matches
#26 —
Recommendation: The Probation Service should learn best practices from Youth Offending Services, especially about how to communicate with offenders to ensure they understand the sentences that are imposed on them. It should also encourage the local delivery of rehabilitative services and …
Response attribution not verified
#25 —
Recommendation: However, lessons can be learnt from Youth Offending Services about the management of the probation population in general, and of young adults in particular. YOSs do not only work with smaller caseloads and with more experienced staff, but are also …
Response attribution not verified
#74 —
Recommendation: We note that the Tax Policy Framework recognises the useful role that informal consultation can play in developing policy. That does not mean, however, that it should be used in place of public consultation when designing policy—particularly as, by limiting …
Response attribution not verified
#68 —
Recommendation: We recommend that HMRC collects data about the sentences handed down for tax fraud, including the number of times the new maximum sentence is imposed by the courts , and provides annual reports of its analysis of this data , …
Response attribution not verified
#67 —
Recommendation: Given that it is four years since the commitment to double the maximum prison term for tax fraud was made, and the importance of a robust evidence base for policy development, we feel that the work to understand the deterrent …
Response attribution not verified
#6 —
Recommendation: A general statutory duty of candour would help to ensure that the priority for public bodies is to establish what has gone wrong and needs to be changed in order to prevent future deaths, rather than protecting individuals and institutions …
Response attribution not verified
#2 —
Recommendation: “Institutional defensiveness” appears to remain a problem for public authorities, particularly when they are involved in public inquiries and inquests. This hinders efforts to establish the truth when things go wrong and stands in the way of fulfilling the State’s …
Response attribution not verified
#14 —
Recommendation: We asked the Cabinet Office whether there should be a permanent body within government that is learning lessons from what went wrong with earlier schemes. Cabinet Office told us that it is the natural place for such learning, considering it …
#13 —
Recommendation: Sir Alan Bates told us of the importance of establishing an organisation that learns lessons from those involved with compensation schemes, including for example victims and lawyers.29 Shaila Pal, Director of the King’s Legal Clinic at King’s College London and …
#11 —
Recommendation: Officials from compensation schemes across government attend eight- weekly meetings of a cross-Whitehall network to share updates on schemes, learning and best practice. The NAO’s report found that these meetings are helpful opportunities for Departments to raise questions on operational …
#6 —
Recommendation: There remains substantial variation across schemes in how long claims take to conclude, capacity for greater transparency and clarity during the claim process and scope for more structured and consistent cross- government learning.8 The independence of schemes, and their design …
#14 —
Recommendation: An organisational culture in which challenge was apparently resented and in which bad news was not escalated appropriately until it was too late lay at the heart of many of the ONS’s problems. This appears to have been addressed by …
#6 —
Recommendation: While there have been enormous problems at the ONS, we also note that not all the commentary about the ONS’s performance has been well-informed, or constructive. Attempts to right long-standing, historical problems have sometimes been used as evidence of the …
#40 —
Recommendation: It is vital that the Department develop a culture of learning from its mistakes. Indications that it has not yet done that include the Department’s response to the Parliamentary and Health Service Ombudsman’s recommendations on 1950s women, repeated problems with …
Response status not verified
#13 —
Recommendation: However, a Department-wide review by the Government Internal Audit Agency (GIAA) in January 2026 found that programme and project teams across the Department were not consistently applying lessons they had identified.25 We asked the Department how it was responding to …
Response status not verified
#12 —
Recommendation: The NAO found the Department had established appropriate steps to identify lessons from other major programmes, but that it needed to go further to embed these in Northern Powerhouse Rail.23 In oral evidence, the Department was clear on the importance …
Response status not verified
#6 —
Recommendation: We are not convinced that the Department has embedded all lessons from past failures into its management of the programme. We recognise that the Department has adapted its approach to Northern Powerhouse Rail in response to lessons from High Speed …
Response attribution not verified
#21 —
Recommendation: There is also no systematic approach for capturing learning from upheld appeals, which could otherwise help reduce avoidable demand and unnecessary pressure on the appeals system.49 These issues have been intensified by pressures on the legal aid system, which the …
Response status not verified
#10 —
Recommendation: The same underlying barriers to improvement of the asylum system have persisted for years, despite multiple attempts at reform. The NAO reported that past interventions were often introduced quickly in response to rising backlogs or changes in asylum policy, without …
Response status not verified
#2 —
Recommendation: The Home Office has yet to demonstrate that it has learned from previous attempts to reform the asylum system, putting it at continued risk of repeating past failures. Recent reform efforts give us little confidence that the Home Office has …
Response attribution not verified
#21 —
Recommendation: NHSE recognised that it needs more evidence to understand which interventions make a difference for patients with frailty and has commissioned a National Institute for Health and Care Research-led evaluation of frailty pathways and interventions.42 Changes to ICBs’ responsibilities
Response attribution not verified
#15 —
Recommendation: Through its close work with us, and our sub-committee, the Independent Commission for Aid Impact (ICAI) is a crucial part of the robust scrutiny architecture which ensures the aid budget is well spent. ICAI’s expert reviews identify areas of good …
Response attribution not verified
#5 —
Recommendation: The Committee are pleased to see the commitment from HMPPS to learn from the current model of delivery. We recommend that HMPPS update the Committee on Coronavirus (COVID-19): The impact on probation systems 23 progress of this piece of work, …
Response attribution not verified
#3 —
Recommendation: We are concerned that lessons have not been learned ahead of a potential second spike of infections. It is not clear that the government is undertaking the necessary preparatory work for a second peak of infections. The Department for Business, …
Response status not verified
#9 —
Recommendation: It is clear that further work needs to be done on the way in which the prison service more generally responds to recommendations. It is important for all organisations that they are able to learn from external sources of assurance. …
Response status not verified
#18 — Committee welcomes DIO offer to share key lessons on safety inspections.
Recommendation: We welcome the offer from DIO to share its key lessons learned on gas and electrical safety inspections. (Recommendation, Paragraph 82)
Response attribution not verified
#5 — MOD's performance recovery claims demand demonstrable improvement in customer experience and trust.
Recommendation: The MOD’s claims of a recovery in performance need to be borne out in a demonstrable improvement in the customer experience and markedly increased customer satisfaction. Service families’ trust has been affected and the DIO and service providers need to …
Response attribution not verified
#3 — Demonstrate DIO has learned crucial lessons from contract delivery failures.
Recommendation: The DIO must prove it has learned lessons from the failures in the delivery of these contracts. (Recommendation, Paragraph 36)
Response attribution not verified
#21 — Cultural change represents the hardest aspect of DWP's service transformation programmes.
Recommendation: DWP acknowledged that cultural change can be the hardest part of any transformation programme. It told us that this requires leadership to help people understand the change that is coming, why the change is a good 35 Qq 19-20 36 …
Response attribution not verified
#4 — Set out monitoring and mitigation strategies for cultural change risks in service modernisation.
Recommendation: Realising the benefits of service modernisation will require strong leadership to embed cultural change within DWP and its outsourced providers. DWP’s Service Modernisation Programme is an 11–year organisation-wide programme estimated to cost £312.1 million, running from 2022–23 to 2032–33, which …
Response attribution not verified
#25 — Home Office refuses to publish extensive lessons learned review from large site acquisitions.
Recommendation: When we questioned the Home Office about repeated mistakes in its acquisitions of large sites, it explained that it was learning from multiple projects at the same time. The Home Office informed us that its lessons learned review identified over …
Response attribution not verified
#5 — Detail lessons from large asylum accommodation site acquisitions and explain process changes to prevent recurrence.
Recommendation: We are not convinced that the Home Office has learned the lessons it identified from its costly acquisitions of large sites. The Home Office claims it has identified “over 1,000” lessons from its acquisition of large asylum accommodation sites. It …
Response attribution not verified
#4 — Address cultural issues allowing Home Office controls and processes to be overridden too easily.
Recommendation: We are concerned that the Home Office’s culture allowed it to override too easily the controls and processes in place to protect taxpayers’ money. The Home Office appears to have been operating in crisis mode for several years and now …
Response attribution not verified
#9 — Companies House and HMRC lack understanding of company register fraud's link to tax losses.
Recommendation: Companies House said that, prior to the introduction of the Economic Crime and Corporate Transparency Act (ECCTA), it estimated that 5% of UK registered companies were fraudulent. It explained that external commentators had estimated the figure could be as high …
Response attribution not verified
#24 — UK's extensive nutrition and food security research resources remain underutilised.
Recommendation: The UK has a tremendous array of research institutes and a strong history of contributing to the fields of nutrition and food security. There is more the Government could be doing to make use of these resources and to integrate …
Response attribution not verified
#25 — Residents still lack sufficient information and transparency regarding their building's remediation progress
Recommendation: In 2020 the previous Committee noted that many residents were not being kept informed about the process of remediation and requested that MHCLG set out how it would improve transparency.42 We therefore asked whether government was now doing enough to …
Response attribution not verified
#20 — Government still faces challenges in robustly evaluating and sharing AI pilot learning.
Recommendation: We questioned DSIT on how it is evaluating and sharing learning from AI pilot activity across government to avoid reinventing the wheel and to support AI adoption at scale. It told us that it was taking a range of approaches …
Response attribution not verified
#19 — Systematic knowledge sharing on government AI adoption remains absent.
Recommendation: The NAO report set out the importance of knowledge sharing to learn from pilot activity, encourage innovation, promote consistent standards, and avoiding duplication of effort in AI adoption across government. However, it also reported that there was no systematic dissemination …
Response attribution not verified
#4 — Establish mechanism for AI pilot learning and scale successful products across government.
Recommendation: DSIT has no systematic mechanism for bringing together learning from pilots and there are few examples of successful at–scale adoption across government. At the time of the NAO report (March 2024), levels of AI use in government were low, but …
Response attribution not verified
#15 — Declining trust in HMRC attributes to substandard services and broader global governmental trends.
Recommendation: We asked about taxpayers’ declining trust in HMRC. HMRC said there had been a decline in trust globally with governments and with public bodies, and it was also subject to that decline. It told us that it had not been …
Response attribution not verified
#14 — Taxpayer trust in HMRC has declined for most groups since the 2020 strategy launch.
Recommendation: In July 2020 HMRC and HM Treasury published the Tax Administration Strategy (the Strategy) which set out how they would build a modern, trusted tax administration system by 2030.23 As part of the Strategy they wanted to gradually increase the …
Response attribution not verified
#2 — Require HMRC to understand and address declining taxpayer trust, publishing concerns and actions.
Recommendation: Taxpayers’ trust in HMRC is falling. Trust in a tax authority is vital for the authority to effectively discharge its role as it affects the willingness of taxpayers to engage and pay the correct amount of tax on time. HMRC …
Response attribution not verified
#18 — Departments remain reluctant to share cyber incident information, hindering collective learning.
Recommendation: We asked the Cabinet Office what the impact was when departments did not share information about their cyber incidents. The Cabinet Office agreed that sharing data is essential to learn lessons, understand vulnerabilities, share best practice and work out what …
Response attribution not verified
#17 — Establish protocols for Defra's professional information sharing and investigate policy leaks.
Recommendation: Defra should ensure that operational and policy decisions are clearly communicated to its arm’s-length bodies and the farming advice service in advance of them being made public. It should investigate the causes of the leaks of its proposed changes to …
Response attribution not verified
#16 — Review and evaluate Government communication with farming sector, providing analysis and solutions.
Recommendation: The Government should review how it communicates with the farming sector and properly evaluate the impact recent communications have had on trust in the Department. It should provide its analysis and proposed solutions in its response to this report. (Recommendation, …
Response attribution not verified
#15 — Improve Defra's proactive and transparent communication with Parliament and arm's-length bodies.
Recommendation: We are thankful to the Secretary of State, Ministers and Officials for engaging with our Committee, but we urge Defra to improve its communication with Parliament and be proactive and transparent in its communications. Similarly, communications between Defra and its …
Response attribution not verified
#14 — Defra's poor communication and last-minute decisions erode trust in farming sector
Recommendation: The experience of the Sustainable Farming Incentive 2024 (SFI24) closure follows a pattern within Defra of poor communication and last-minute decision-making following rumours and Departmental leaks. As with the sudden closure of the Capital Grants scheme in November 2024, the …
Response attribution not verified
#6 — Require Government to consult stakeholders and clearly communicate ELMS future direction
Recommendation: A transparent policy on the direction of the Environmental Land Management Schemes (ELMS) and other subsidy arrangements is crucial. If the Government is serious about improving ELMS outcomes it must consult with stakeholders and communicate its plan clearly. Confidence in …
Response attribution not verified
#17 — Government lacks comprehensive understanding of effective VAWG interventions and mechanisms to share good practice.
Recommendation: Government departments have a limited understanding of what works to tackle violence against women and girls (VAWG). Since 2021–22, the Home Office has spent at least £4.2 million on new research into what works, but the projects funded are not …
Response attribution not verified
#9 — Home Office failed to sufficiently embed specialist VAWG sector expertise in strategy development.
Recommendation: Throughout its 2021 VAWG Strategy, the Home Office did not make the most of the available expertise and knowledge, for example by engaging with the voluntary sector to understand the demands being faced on the frontline.17 Evidence submitted by End …
Response attribution not verified
HSSIB safety recommendations(111)— showing 50 strongest matches
Surgical care of NHS patients in independent hospitals
This investigation identified opportunities to improve the way learning from patient safety incidents involving NHS-funded patients is shared across independent sector providers. The Independent Healthcare Providers Network has developed and ratified an agreed process to support anonymous sharing of learning …
Safety Action
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you ensure that temporary staff know how to speak up and that they feel safe to raise concerns?
Learning Prompt
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you enable temporary workers to feed back on their experiences of working in your organisation, to understand the organisational culture in relation to this group?
Learning Prompt
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
Organisations that provide temporary staff to the NHS can improve patient safety by including information about the NHS England Learn from Patient Safety Events service to temporary staff as part of their onboarding process. This is to enable temporary staff …
Safety Observation
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
HSSIB recommends that the National Guardian’s Office, working with relevant stakeholders, identify the barriers that prevent temporary staff from speaking up and develops mechanisms to address those barriers. This will build on their work to explore barriers for other staff …
Safety Recommendation
Digital tools for online consultation in general practice
National healthcare organisations can improve patient safety by supporting general practices to report patient safety incidents associated with the use of online consultation tools.
Safety Observation
Temporary staff – involvement in patient safety investigations
How do you ensure that learning is fed back to those staff involved, including temporary staff?
Learning Prompt
Temporary staff – involvement in patient safety investigations
Can you work with employment agencies to create agreed methods of including temporary staff in learning responses through your contractual arrangements?
Learning Prompt
Temporary staff – involvement in patient safety investigations
Do you have processes in place so you can conduct interviews with temporary staff?
Learning Prompt
Temporary staff – involvement in patient safety investigations
How do you engage temporary staff in a learning response?
Learning Prompt
Temporary staff – involvement in patient safety investigations
Agencies providing temporary staff to the NHS can improve patient safety by facilitating the involvement of temporary staff in investigation processes, including interviews. This is to enable the investigation of patient safety incidents in line with the Patient Safety Incident …
Safety Observation
Temporary staff – involvement in patient safety investigations
HSSIB recommends that NHS England includes guidance on engaging temporary staff in learning responses within their 'engaging and involving patients, families and staff following a patient safety incident'. This should be developed in collaboration with providers of temporary staff to …
Safety Recommendation
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Develop training in after action review and thematic analysis which includes a practical component where learners have an opportunity to apply the approach, to help ensure these learning responses are effective.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Increase access to education and training, focused on the application of system-based tools, and taught by people with demonstrable expertise, to help staff to carry out system-based investigations.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Support networks for knowledge sharing and collaboration for investigation staff to help foster learning about investigation practice.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide guidance on the practical steps to take to decide on the most appropriate learning response to an incident, to help organisations adopt a robust, standard approach to their decision making.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide greater clarity on the role of PSIRF investigations and other learning responses in the coronial process to help support organisations subject to a coroner’s inquest.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide details of the support and resource expected from integrated care boards to facilitate cross-organisational investigations, to help reduce uncertainty and variation in practice.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Support PSIRF education and training to focus on the practical application of PSIRF tools, taught by people with demonstrable expertise in applying a system-based approach and tools in investigations.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Publish examples of patient safety incident investigations which include the PSIRF system-based tools and guides used to help investigators understand their application. Examples may be particularly beneficial in sectors that may have struggled with, or be new to, implementing PSIRF.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Review and refresh the PSIRF learning response toolkit, to include the use of multimedia guides, to help make the tools and guides easier for investigators to use.
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation share learning from the implementation and ongoing optimisation of EPR systems to support other organisations?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
Does your organisation have routes for staff to raise concerns about the EPR system they use, with feedback to inform staff of actions taken in response?
Learning Prompt
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.
Safety Observation
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you facilitate shared learning opportunities for staff across different organisations?
Learning Prompt
Electronic patient record systems – risk from loss of functionality
Learn from events to develop EPR system and organisational resilience.
Investigation Scope
Wrong patient details on blood sample
Trusts can aim to incorporate human factors thinking and awareness within incident reporting and investigation.
Learning Prompt
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to facilitate shared learning across the NHS so that effective strategies that have been adopted by local NHS organisations for the management of staff fatigue and emotional wellbeing can be shared.
Safety Observation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHS England and NHS Improvement responds to emerging scientific evidence and shared learning when reviewing guidance for NHS trusts on the role of hospital ventilation systems in nosocomial transmission.
Safety Recommendation
Support for staff following patient safety incidents
It would be beneficial for organisations to implement programmes to support staff following patient safety incidents, taking into consideration the findings in this report relating to context, individualisation, delivery and investigation.
Safety Observation
Support for staff following patient safety incidents
It would be beneficial if the impact of programmes to support staff following patient safety incidents were subject to formal evaluation. This would assist understanding of what is good practice in terms of support delivered and resource required.
Safety Observation
Never events: analysis of HSIB's national investigations
It would be beneficial if significant safety events, such as those presented in this national learning report, continue to be reported and investigated by NHS organisations without apportioning blame or liability, using a recognised systems- based approach such as the …
Safety Observation
Local integrated investigation pilot 1: Incorrect patient identification
‘Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June 2020’ (Healthcare Safety Investigation Branch, 2021a)
Learning Prompt
Unintentional overdose of morphine sulfate oral solution
It may be beneficial if professional bodies provided guidance and further support to their members to maximise the learning that can be achieved from safety investigations that may improve patient care.
Safety Observation
The use of an appropriate flush fluid with arterial lines
It may be beneficial to recognise that safety risks are not reliably reported and therefore that the likelihood and level of harm may not be accurately reflected through existing reporting systems.
Safety Observation
HSIB’s local investigation pilot: shared learning for local healthcare systems
It may be beneficial if providers of NHS care consider low-harm and no-harm safety events as sources of learning in local patient safety incident response plans.
Safety Observation
HSIB’s local investigation pilot: shared learning for local healthcare systems
It may be beneficial if healthcare organisations develop processes to identify safety improvement themes from patient safety investigation reports.
Safety Observation
HSIB’s local investigation pilot: shared learning for local healthcare systems
It may be beneficial if local healthcare systems consider how best to support the investigation of cross-organisation safety events as they implement the Patient Safety Incident Response Framework.
Safety Observation
The assessment of venous thromboembolism risks associated with pregnancy and the postnatal period
It may be beneficial for organisations that make recommendations to improve the safety and care of pregnant women and pregnant people during their pregnancy and up to 6 weeks after birth, to have a process for reporting on responses to …
Safety Observation
Care delivery within community mental health teams
HSIB recommends that NHS England works with appropriate stakeholders, including experts with appropriate experience, to create guidance on culture change. A quality improvement programme should also be developed to support practitioners in undertaking psychosocial assessments that are in line with …
Safety Recommendation
Patients at risk of self-harm: continuous observation
Is there a mechanism to allow for shared learning and reflection between care providers involved in caring for patients at risk of self-harm?
Learning Prompt
Sexual safety: the implications for patient safety
There is an opportunity for health and care organisations to share learning around implementing the 10 principles of NHS England’s ‘Sexual safety in healthcare – organisational charter’. This would enhance shared knowledge, understanding and mechanisms for embedding the principles.
Safety Observation
Safety management
Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended …
Safety Observation
12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence
Acute hospitals and ambulance services can improve patient safety by developing local mechanisms to share information about patient outcomes where paramedics have undertaken a 12-lead ECG. This can help to support learning for paramedics and provide feedback on where their …
Safety Observation
The impact of staff fatigue on patient safety
HSSIB recommends that the NHS Staff Council, via the Health, Safety and Wellbeing subgroup, convenes fatigue science experts and other key stakeholders to develop and test a consensus statement defining fatigue for all healthcare staff. The group should work with …
Safety Recommendation
Mental health inpatient settings
HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are …
Safety Recommendation
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
NHS England, working with the National Collaborating Centre for Mental Health, is identifying 10 organisations to lead work to co-produce personalised approaches to safety planning in inpatient services. The learning will be shared through national learning networks. This is expected …
Safety Action
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for …
HSSIB recommends that the Department of Health and Social Care continues to work with the ‘recommendations but no action working group’ and other relevant organisations, to ensure that recommendations made by national organisations specific to mental health inpatient settings are …
Safety Recommendation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
Integrated care boards and organisations that provide mental health care can improve safety by involving people with lived experience and family carers in coaching for executive leaders. This could include creating learning networks within provider collaboratives. By embedding these roles, …
Safety Observation
NCEPOD recommendations(11)
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Testicular Torsion
Wording not shown. See the report on NCEPOD's website.
Testicular Torsion
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
CQC inspection actions(335)— showing 50 strongest matches
Worthing Hospital
The trust must ensure organisational wide learning is shared within the trust to reduce the risk of repeated incidents.
Must Do
William Harvey Hospital
The trust should ensure they have systems and processes in place to ensure all incidents, regardless of whether they result in harm, are reported.
Should Do
William Harvey Hospital
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses. 17(2)(b): Good governance
Should Do
William Harvey Hospital
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses. 17(2)(b) Good governance
Should Do
University Hospital of Hartlepool
The service should ensure that incidents are reviewed and thoroughly investigated by competent staff, and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result.
Should Do
The York Hospital
The trust should ensure that staff receive feedback from incidents.
Should Do
The York Hospital
The service must ensure executive, care group and operational leads and managers are responsive, supportive and take action when ED staff need help.
Must Do
The York Hospital
The trust must gain assurance that learning from incidents and risks are shared within the organisation to prevent the risk of reoccurrence.
Must Do
The York Hospital
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Must Do
The York Hospital
The trust must ensure the organisations supports all staff, including those with particular equality characteristics, to feel respected and valued and supports an environment where staff are encouraged to speak up and raise concerns without fear of blame or reprisal.
Must Do
The Royal Free Hospital
The trust should ensure that as many staff as possible are aware of the learning from incidents.
Should Do
The Ipswich Hospital
The service must ensure robust review of incidents to ensure they are appropriately graded and managed to keep women and babies safe and ensure appropriate follow up care is provided.
Must Do
St Richard's Hospital
The trust must ensure organisational wide learning is shared within the trust to reduce the risk of repeated incidents.
Must Do
St Austell Hospital - Penrice Birthing Unit
The service should ensure that there are effective processes for learning from incidents at birth centres.
Should Do
St Albans City Hospital
The trust should have systems and processes in place to ensure that staff are aware of any recent medicine related incidents and share learning from incidents.(Regulation 12).
Should Do
South Tyneside District Hospital
The trust must implement an effective system to learn from deaths which ensures deaths are appropriately and consistently screened, further review is undertaken where required and lessons learnt are effectively identified and shared with teams.
Must Do
South Tyneside District Hospital
The trust must implement an effective system to identify, report and learn from incidents involving the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
South Tyneside District Hospital
The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within inappropriate timescales. The system must ensure incidents are effectively …
Must Do
Scarborough Hospital
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively …
Must Do
Scarborough Hospital
The trust must gain assurance that learning from incidents and risks are shared within the organisation to prevent the risk of reoccurrence.
Must Do
Scarborough Hospital
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Must Do
Scarborough Hospital
The trust must ensure the organisations supports all staff, including those with particular equality characteristics, to feel respected and valued and supports an environment where staff are encouraged to speak up and raise concerns without fear of blame or reprisal.
Must Do
Salford Royal Hospital
The trust should ensure it continues to improve culture and support staff to speak up.
Should Do
Salford Royal Hospital
The trust should ensure serious incidents are investigated in a timely manner and learning is shared across the organisation as required.
Should Do
Royal Victoria Infirmary
The service should continue to act on concerns to improve culture within the Paediatric Intensive Care Unit.
Should Do
Royal Victoria Infirmary
The service must ensure learning from never events is shared with all staff.
Must Do
Royal Victoria Infirmary
The service must ensure learning from never events is shared with all staff.
Must Do
Royal Victoria Infirmary
The service must ensure ways to improve access to management, the staff experience, and methods to improve staff morale.
Must Do
Royal Victoria Infirmary
The trust must ensure it encourages the identification, reporting and investigation of incidents and risks in a timely fashion and shares learning to improve safety and quality of the service.
Must Do
Royal Victoria Infirmary
The trust must ensure that staff are able to report service user safety concerns without fear of reprisal, retribution or detriment using internal routes and in line with policies and procedures.
Must Do
Royal Victoria Infirmary
The trust must ensure its supports all staff, including those with particular equality characteristics, to feel respected and valued and support an environment where staff are encouraged to speak up and raise concerns without fear of blame or reprisal.
Must Do
Royal Sussex County Hospital
The trust must ensure cultural concerns in the theatre department are addressed, and action is taken to ensure this improves.
Must Do
Royal Hallamshire Hospital
The trust must continue to improve lessons learned and the sharing of lessons learned amongst the whole team and the wider service.
Must Do
Royal Hallamshire Hospital
The trust must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Royal Hallamshire Hospital
The trust must ensure incidents including serious incidents are investigated within an appropriate timescale and improvements are made without delay.
Must Do
Rochdale Infirmary
The trust should ensure it continues to improve culture and support staff to speak up.
Should Do
Rochdale Infirmary
The trust should ensure serious incidents are investigated in a timely manner and learning is shared across the organisation as required.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure medical staff complete exception reports to identify trends and themes and use these to improve services for patients and staff.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all staff report incidents via the trust reporting systems.
Must Do
Princess Royal Hospital
The hospital should consider how to improve staff confidence in raising concerns to senior leaders.
Should Do
Pilgrim Hospital
The trust should ensure effective systems are in place to investigate incidents in a timely manner and identify and share learning from incidents to prevent further incidents from occurring.
Should Do
Pilgrim Hospital
The trust should consider monitoring staff’s compliance with the systems in place to enable learning from incidents.
Should Do
North Middlesex University Hospital
The service must contribute to strengthening governance processes by supporting the timely completion of safety incident reviews, mortality reviews and complaints. The service must also ensure assurance checks are completed robustly and where needed improvements take place.
Must Do
North Middlesex University Hospital
The trust must ensure that learning and improvements take place in a timely manner by ensuring the investigations into complaints, incidents and mortality are concluded within stated timescales.
Must Do
North Middlesex University Hospital
The trust must ensure that services where there is a poor culture are identified and offered appropriate support to bring sustained improvement.
Must Do
North Manchester General Hospital
The trust should ensure all staff recognise and report incidents.
Should Do
North Manchester General Hospital
The service should continue to address the identified issues in culture at the service to ensure safe service delivery.
Should Do
Northern General Hospital
The trust must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Northern General Hospital
The trust must continue to improve lessons learned and the sharing of lessons learned amongst the whole team and the wider service.
Must Do
Northern General Hospital
The trust must continue to improve and embed processes for investigating serious incidents.
Must Do
HMICFRS recommendations(4)
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures …
Recommendation
FRS 2021-22 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The service has shown a clear intent from the executive board to improve the culture of the service. However, more needs to be done throughout the organisation. We have found evidence of poor behaviours that are not …
Recommendation
An inspection of the effectiveness of the police and law enforcement bodies' …
With immediate effect, take effective steps to eradicate victim-blaming language in their forces
Recommendation
ICIBI immigration recommendations(3)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 9 Review the assurance regime at Stansted and relaunch it so that it is no longer regarded as a “tick-box exercise” with little value, ensuring that those responsible for …
An inspection of Border Force operations at Stansted Airport
Recommendation 9 Review the assurance regime at Stansted and relaunch it so that it is no longer regarded as a “tick-box exercise” with little value, ensuring that those responsible for …
An inspection of contingency asylum accommodation (November 2023 – June 2024)
Strengthen organisational learning in relation to asylum accommodation by producing a framework, with associated processes and guidelines, for capturing, evaluating and sharing learning (‘best practice’ and pitfalls) from ‘business as …
PPO death in custody recommendations(29)
The Prison Group Director for East Midlands
The Prison Group Director for East Midlands should share the Ombudsman’s report with the regional safety lead.
The Governor of HMP Woodhill
The Governor of Woodhill should share this report with the Deputy Governor and CM A and discuss the Ombudsman’s findings with them.
The Governor
The Governor should ensure that all evidence about a death in custody, including electronic evidence, is retained and promptly made available to the Prisons and Probation Ombudsman, in line with PSI 58/2010.
The Governor at HMP Peterborough
The Governor at HMP Peterborough should ensure that a manager holds a hot debrief promptly after a death in custody and that all those involved in the incident, including healthcare staff, are invited to attend, in line with PSI 64/2011.
The Governor
The Governor should ensure that all evidence relevant to a death in custody is retained and that evidence is made available to the PPO, in line with PSI 58/2010.
The Head of Healthcare
ensure that a copy of this report is shared with Dr A, and that his employing agency discusses the Ombudsman’s findings with him.
The Department of Home Affairs
The Department of Home Affairs should consider immediately commissioning an independent investigation in the event of any future non-natural deaths at Isle of Man Prison.
The Governor and Head of Healthcare (HMP Bristol)
The Governor and Head of Healthcare will want to consider this finding and conduct their own investigations to establish what happened and whether there is any learning.
The Governor
The Governor should ensure that this report is shared with Officer A and that a senior manager discusses the Ombudsman’s findings with him.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Director
The Director should share this report with PCO A and PCO B and ensure that a senior manager discusses the Ombudsman’s findings with them.
The Governor
The Governor should ensure that the Prisons and Probation Ombudsman is promptly provided with all requested documents following a death in custody, in line with PSI 58/2010.
The Governor
The Governor should investigate the staff culture on B Wing, including considering the number and nature of complaints submitted, and provide an update to the Ombudsman.
The Governor
The Governor should share a copy of this report with CM A and arrange for a senior manager to discuss the Ombudsman’s findings with him.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor of HMP Liverpool
The Governor should ensure that a copy of this report is shared with all staff named in this report so that they are aware of the Ombudsman’s findings.
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that a copy of this report is shared with the staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor
The Governor should share a copy of this report with Officer A and ensure that a senior manager discusses the Ombudsman’s findings with him.
The Head of Healthcare
The Head of Healthcare should share a copy of this report with Senior Nurse A and Nurse B and discuss the Ombudsman’s findings with them.
The Head of Healthcare
The Head of Healthcare should share this report with Nurse A and discuss the Ombudsman’s findings with her.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that this report is shared with all staff named in it and that they are given the opportunity to reflect on the learning involved.
The Governor and Head of Healthcare of HMP Liverpool
Healthcare staff were not invited to the debrief after Mr Fielding died. Those we interviewed said they had not felt adequately supported. We bring this to the attention of the Governor and Head of Healthcare.
The Director General of HMPPS
The Director General of HMPPS should communicate to Governors and Directors his expectation that in all but the most exceptional of circumstances, when there is evidence of making deliberate false entries, a formal investigation is instigated and, in appropriate circumstances …
The Head of Healthcare, alongside doctors involved in Mr Honnor’s …
The Head of Healthcare, alongside doctors involved in Mr Honnor’s care, should undertake a formal significant event analysis to identify weaknesses in the care provided and learning from these, and share these with all clinicians working in the prison.
The Governor
The Governor should ensure that, in accordance with PSI 64/2011, a manager holds a hot debrief promptly after a death in custody and that all staff involved in the incident, including healthcare staff, are invited to attend.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that this report is shared with all staff named in it and that they are given the opportunity to reflect on the learning involved.
The Governor of HMP Lewes
The Governor will wish to assure himself that the processes in place are adequate to ensure prisoners are offered appropriate support following a death in custody, in particular in the case of close friends of the deceased prisoner.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are offered appropriate support following a death in custody.
The Governor
The Governor should conduct a local investigation into the events of 27 June 2024, identify and share any learning with staff and the Ombudsman, and ensure that night patrol officers understand the equipment they are required to carry, when and …
IOPC learning recommendations(6)
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take steps to ensure that when it has been identified that an officer has failed to report or challenge improper conduct, whether or not misconduct processes are initiated against that officer, appropriate steps …
Recommendations - Metropolitan Police Service, August 2021
The IOPC recommends the MPS ensures that changes implemented to develop a culture of openness, transparency, improve cross-team working and collaboration between teams are embedded and a clear plan is in place to support continuous improvement in this area. An …
Inappropriate photographs taken at crime scene – Metropolitan Police Service, June 2020
The IOPC recommends the Metropolitan Police Service reviews whether supervisors and senior management at Forest Gate Police Station are taking personal responsibility to identify and eliminate patterns of inappropriate behaviour, whilst simultaneously promoting a safe and open culture which makes …
Inappropriate photographs taken at crime scene – Metropolitan Police Service, June 2020
The IOPC recommends the Metropolitan Police Service take steps to ensure all officers within Forest Gate Police Station conform to the expectations of their behaviour under the Code of Ethics, whilst on and off duty, and are aware that failure …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police adopts the principles set out in the force FLO policy as best practice for all officers/staff when dealing with bereaved families. There should be clear agreement in advance about what information can be …
National recommendations - College of Policing, July 2024
The IOPC recommends the College of Policing and the National Police Chiefs’ Council (NPCC) work together to produce clear guidance on preservation of life at the scene of a hanging where death has not been confirmed. This should include guidance …
NAO audit recommendations(30)
Investigation into student finance for study at franchised higher education providers
establish a common anti-fraud and corruption culture and risk tolerance by, for example, encouraging the reporting of fraud and corruption and embedding discussions in risk management forums
Accepted
Investigation into whistleblowing in the civil service
d Cabinet Office should build on its efforts to help departments learn from different approaches to whistleblowing, focusing on areas such as supporting effective assurance by senior leaders and Audit and Risk Assurance Committees, understanding whistleblowers? experience and supporting the …
Accepted
Investigation into whistleblowing in the civil service
b Cabinet Office should work with departments to encourage them to use every concern raised as an opportunity to learn from whistleblowers, including those concerns where no wrongdoing is found;
Accepted
Managing conflicts of interest
Cabinet Office encourages each public body to commission their internal auditors to review their implementation of the standard, including whether mitigations have been properly implemented. To help with this, it should invite the Government Internal Audit Agency (GIAA) to participate …
Partially accepted
Managing conflicts of interest
Cabinet Office facilitates the creation of a temporary good practice forum which would allow public bodies to build networks and learn from each other as they implement the minimum standard;
Accepted
Investigation into whistleblowing in the civil service
c When data is available Cabinet Office should use it to establish the extent of whistleblower complaints of intimidation or victimisation, build an understanding of the number of and patterns in complaints, and consider any need to coordinate departmental action
Accepted
Investigation into whistleblowing in the civil service
a In order to build a fuller understanding of whistleblowing outcomes and what happens to whistleblowers, Cabinet Office should work with departments to improve the completeness of data, broaden the categories of data it collects and deepen the analysis it …
Accepted
Managing NHS backlogs and waiting times in England
c) Before April 2023, NHSE should set up independent evaluations of its major elective recovery programmes so that it is actively developing the evidence base for these initiatives.
Accepted
Regulating the financial sustainability of higher education providers in England
The OfS should: d) communicate more effectively with the sector to build trust in its approach as a regulator; improve providers’ understanding of its attitude to risk and how it defines risk-based, proportionate, regulation; and be more ready to share …
Accepted
Decommissioning Sellafield: managing risks from the nuclear legacy
Sellafield should: carry out an assessment of the culture across the site and develop suitable metrics to assess and monitor whether all areas of the site and its leadership are positively contributing to creating a high performing public sector organisation.
Accepted
Investigation into student finance for study at franchised higher education providers
increase activity to raise awareness among lead providers of the risks and benefits associated with using franchised providers. This could include sharing good practice and setting out the consequences (including student loan funding being recovered or commercial damage) should concerns …
Accepted
Investigation into student finance for study at franchised higher education providers
as a matter of urgency OfS and DfE should jointly reiterate to the higher education sector its role in preventing fraud and abuse, and particularly to lead providers that they bear direct responsibility for the governance and management practices of …
Accepted
Progress in improving mental health services in England
a) DHSC and NHSE should publish a detailed statement of what achieving full 'parity of esteem' between mental and physical health services encompasses, in terms of access and service standards, staffing model and funding allocations, and the road map for …
Accepted
Government Shared Services
k) Departments working together as clusters should each complete a ?lessons identified? assessment to demonstrate how they have taken on board lessons from previous strategies and share these with the Cabinet Office.
Accepted
The production and distribution of cash
The Mint and the Bank should maximise opportunities to learn from each other’s experiences of cash production and work with the wider distribution system, for example working closely with industry, and making best use of available production capacity.
Accepted
Financial sustainability of colleges in England
e) Learn lessons from the first two college insolvency cases. This work should include evaluating the cost, timeliness and impact of the education administration process and identifying improvements for future cases.
Accepted
Financial sustainability of colleges in England
b) Assess systematically how far colleges are responding to financial pressures by narrowing their provision and reducing student support services. This work should include identifying colleges that have made efficiency savings without curtailing provision, and sharing this good practice across …
Accepted
Tackling the tax gap
c) while recognising that it is appropriate for HMRC to primarily organise its approach to compliance by risk and customer group, consider extending, where relevant to other tax gap behaviours, good practice shown in its tax avoidance strategy and approach. …
Accepted
BBC Studios
The BBC should: a) develop a clear plan for closing the cultural gap between the production and distribution arms of BBC Studios, including milestones and indicators for measuring its progress in achieving this.
Accepted
Government's general grant schemes
To improve grant practitioners' capability, the Grants Management Function should (f) explore further opportunities to share good practice, resources and experiences among grant practitioners within central and local government, such as holding in-person network meetings outside of London, and making …
Accepted
The effectiveness of government in tackling homelessness
We recommend that DLUHC should establish a way for local authorities to more easily understand innovative practice and potential solutions in homelessness services from other authorities.
Accepted
Investigation into student finance for study at franchised higher education providers
more systematically share data and testing results, such as from statistical testing to identify anomalies or targeted sampling of provider data audits, to better understand risks and focus investigative work
Accepted
Investigation into student finance for study at franchised higher education providers
develop further guidance for providers explaining what constitutes meaningful student course engagement and how it expects providers to self-assure data. As part of this, DfE should consider what SLC and OfS need to better assess the quality of provider data, …
Accepted
Progress in improving mental health services in England
e) As mental health services will need to remain the focus of sustained improvement and in the light of national and local reorganisation of health bodies, DHSC and NHSE should set out the future approach to leading, monitoring and assuring …
Accepted
Progress in improving mental health services in England
c) NHSE, working with local ICBs and providers, should improve its data and analysis to better understand the relative cost and cost-effectiveness of different services, and provide a more robust basis to decide future priorities.
Accepted
Central oversight of arm’s-length bodies
The Cabinet Office, departments and ALBs should work together to develop and share performance information between ALBs, to help identify opportunities for improvement.
Accepted
Protecting consumers from unsafe products
e) Examine how best to influence businesses and consumers to prevent problems from occurring. This could include business segmentation analysis to ensure regulators can influence harder-to-reach businesses and assessing what impact the OPSS could have by more directly trying to …
Accepted
Public Service Pensions
d) consider government’s overall approach to ensuring that employees understand their pensions, particularly for the three million scheme members affected by the McCloud judgment who will need reliable and timely information, including from scheme administrators, to make decisions about their …
Accepted
Public Service Pensions
b) resolve its concerns about the cost control mechanism and be open and transparent about the impact of any changes it makes for employers and scheme members;
Accepted
Achieving government’s long-term environmental goals
• defines the values and behaviours that will support delivery of its environmental goals, reviews how closely these align with its current working culture and sets out plans for improving and monitoring progress.
Accepted
PHSO ombudsman recommendations(4)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Ignoring the alarms: How NHS eating disorder services are failing patients
NICE should consider including coordination as an element of their new Quality Standard for Eating Disorders.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
IMB annual reports(11)
Moorland (2023)
HMP/YOI Moorland is a Category C public sector resettlement prison for adults and young offenders, also serving as a foreign national hub, with an operational capacity of 1,058. The report highlights generally good accommodation and staff-prisoner relationships, with improvements in healthcare waiting times and education access. However, key concerns persist regarding staffing levels impacting regime and key work, ongoing issues with illicit substances, and significant delays in mental health transfers to specialist units, alongside a lack of prisoner confidence in the complaints system.
PRISON
Key concerns
Low Newton (2023)
HMP/YOI Low Newton is a well-managed women's prison that successfully adapted its regime post-Covid. While praised for its safe environment, estate improvements, and dedicated staff, it is significantly hampered by staff shortages, impacting regime delivery and key worker scheme consistency. The Board highlights concerns regarding funding for essential facilities, the management of complex prisoners, and the need for improved transport arrangements and oversight of disciplinary processes.
PRISON
Key concerns
Standford Hill (2023)
HMP/YOI Standford Hill is recognized as a well-run Category D prison, excelling in resettlement and providing substantial opportunities for prisoners to gain skills and employment, contributing to low re-offending rates. The prison maintains a safe environment with zero reported self-harm, assaults, or deaths in custody during the reporting period, and healthcare provision has significantly improved. Key concerns include the persistent poor performance of GFSL, the potential negative impact of the TPRS on resettlement, and the need for scanning equipment and modern monitoring technology.
PRISON
Key concerns
Thameside (2023)
HMP Thameside, a local Category B/C prison, maintained a safe environment despite a high remand population and gang-related challenges, though prisoner-on-prisoner assaults increased. The transition to a new healthcare provider was problematic, negatively affecting prisoner access to care, and issues with property management and resettlement support persist. The Board also noted ongoing concerns regarding the effectiveness of the key worker scheme, in-cell computer systems, and delays in mental health transfers.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
This report highlights significant shortcomings in the Short-term Holding Facilities (STHFs) in Scotland and Northern Ireland. Key issues include a failure to separate men and women at Larne House, inadequate accommodation, and inconsistent healthcare provision often leading to the removal of essential medication. Detainees frequently face unnecessarily long stays due to systemic inefficiencies, coupled with a lack of transparency and accessibility challenges across the estate.
PRISON
Key concerns
Yarl’s Wood IRC (2024)
Yarl's Wood IRC experienced a 40% increase in detainee throughput in 2024, operating close to its 444-person capacity. While staff are commended for humane treatment and effective incident management, concerns persist regarding high levels of violence, inappropriate detention of vulnerable individuals, and poor information sharing. The Board highlights issues with prolonged detention, slow casework progression, and the inappropriate use of the CSU for mental health cases, noting that staff recruitment and retention remain challenging.
IRC
Key concerns
Rochester (2025)
Rochester experienced an exceptionally challenging year marked by leadership instability and an HMIP Urgent Notification highlighting long-standing failures. While safety metrics showed improvement and staff interactions with prisoners were generally positive, the prison grappled with dilapidated infrastructure, persistent property issues, and staffing shortages impacting the regime. Major cohort changes were implemented too quickly, creating significant logistical demands.
PRISON
Key concerns
Hewell Grange (2020)
This report covers the final six months of HMP Hewell Grange as it underwent a planned closure, ceasing to hold prisoners by 31 March 2020. The Board found the prison generally safe and praised staff for their humane management of the closure, despite unacceptable living conditions. Healthcare provision was inconsistent, and purposeful activity was curtailed due to the closure, though efforts were made to minimise negative impacts on resettlement.
PRISON
Key concerns
Hewell (2020)
The COVID-19 pandemic significantly impacted HMP Hewell, leading to a full lockdown, 23.5-hour cell confinement, and cessation of most activities. While staff are commended for averting a direct catastrophic impact from the virus and improving cleanliness, concerns remain regarding prisoner welfare, mental health, and rehabilitation. The prison saw leadership changes and continued a journey of improvement after years of poor performance, with some areas showing progress despite ongoing challenges in safety, healthcare provision, and regime delivery.
PRISON
Key concerns
Standford Hill (2022)
HMP/YOI Standford Hill, a Category D open prison, successfully maintained operations during the reporting period despite COVID-19, achieving low infection rates and a strong focus on prisoner rehabilitation, reflected in low reoffending. The IMB noted humane treatment of prisoners, dedicated healthcare, and an excellent record in providing work opportunities. Key concerns include poor performance by GFSL, inadequate technological support, and the deteriorating state of the prison's estate.
PRISON
Key concerns
Grendon (2023)
HMP Grendon, a Category B therapeutic prison, maintained its core function and safety despite an increase in self-harm and violence intelligence reports. However, the Board raised significant concerns including persistent staff shortages impacting therapy and education, an ongoing rat infestation, and an inadequate night sanitation system. Patient satisfaction with healthcare significantly declined, exacerbated by a critical lack of data, while delays in a fire safety project and the issue of men unable to move out of therapy caused further disruption.
PRISON
Key concerns
IMB individual recommendations(72)— showing 50 strongest matches
Cookham Wood (2021)
When will the YCS allow full-time education to resume for boys in Cookham Wood so they can return to pathway-based education ?
HMPPS
In Progress
Lowdham Grange (2024)
What action is being taken to address HM Coroner’s stated concerns, including: a failure to investigate whether anything could have been done to prevent the deaths; failure to seek any lessons from the deaths; failure to implement any findings of the Prisons and Probation Ombudsman (PPO); and the failure to inform staff of policies and procedures relating to the deaths, …
Governor / Director
Noted
Lowdham Grange (2024)
What action is being taken to address the serious issues raised by HM Coroner through the Prevention of Future Deaths notices relating to deaths in custody at HMP Lowdham Grange and, particularly, the cited lack of candour by managers and officers?
Governor / Director
Noted
London STHF (2024)
The Board stopped receiving Safer Detention Reports in July 2023 and despite many requests, these have not been forthcoming. This means that we do not have access to the data to enable us to monitor Suicide and Self Harm Warning Forms, Vulnerable Adult Warning Forms and Use of Force. After repeated requests at every Board meeting, we were eventually told …
Other
Dartmoor (2023)
Can the implementation of the Action Plan, and the monthly progress reports issued as a result of the recent report into the prison by HMIP Inspectors be shared regularly with the IMB?
Governor / Director
Oakwood (2025)
Can the Director facilitate the installation of IMB information noticeboards in the admissions area and on the induction wings to further inform and promote the work of the IMB?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
We request clarity on what remedies have been or are to be introduced to prevent this failure in the future.
Other
Dovegate (2025)
The Board asks that the Director ensures the culture of continuous improvement becomes permanently ingrained at Dovegate.
Governor / Director
Noted
Brinsford (2023)
The Board is fully aware of the difficult culture within Brinsford and fully aware of the attempts you have made to change it, to no avail. Improved supervision by middle managers and having experience in other establishments might be helpful.
Governor / Director
Brinsford (2023)
This year the standards coaching team were brought in to train and upskill officers, they also gave them the confidence to challenge prisoners. They have been instrumental in getting officers out of their comfort zone. We eagerly wait to see the improvements becoming part of the daily routine.
Governor / Director
Brinsford (2023)
Following the complete lockdown of the prison during the pandemic, the Board feels some officers became lax in fulfilling their duties, and many lacked the experience of a busy active prison and took the easy option where possible.
Governor / Director
Brinsford (2023)
The Board recognises that the senior leadership team are enthusiastic, talented and energised to take forward your ideas to improve prisoner outcomes; however the messages did not reach the officers who carry out these management decisions, or they failed to carry out the directions.
Governor / Director
Isle of Wight (2020)
The HMIP inspection identified four areas that required external support from HMPPS; the subsequent Independent Review of Progress (IRP) report noted that: ‘these were rejected and so no progress had been made’. The IRP visit in January 2020 noted improvement by local management but there was a lack of support from the Prison Service nationally – including in ensuring basic …
HMPPS
In Progress
Featherstone (2020)
The restrictions introduced to deal with the COVID-19 pandemic have resulted in the cessation of education programmes, rehabilitation initiatives and many key worker contacts which are fundamental to the completion of sentence plans. While the Board understands the reasons for the constraints, they have an adverse impact on the life chances of prisoners and the achievement of a rehabilitative culture. …
HMPPS
Bedford (2020)
Learn the positive lessons of COVID-19 – for example, the importance of predictable regimes, smaller groups, more interaction, fewer drugs and regular contact with families.
Governor / Director
Accepted
Bedford (2020)
Ensure that the decrease in prisoner-on-prisoner violence during the COVID-19 crisis is not used as an excuse to maintain lockdown conditions. Analyse all the lessons of the crisis and take actions accordingly.
HMPPS
Accepted
Wealstun (2021)
Ensure that as prisons move out of lockdown a review is undertaken to identify any long-term effects on prisoners and plans are in place to address them (repeat area from 2019/2020 report).
HMPPS
In Progress
Gartree (2021)
Will the Governor work with the Board to identify ways to continue to improve engagement between the Board and the SMT? The Board acknowledges that aspects of the working relationship have improved, but there are still occasions when the flow of information relies on us asking questions. We are keen to have key information provided so that we have the …
Governor / Director
Cookham Wood (2021)
However, the IMB believes this should be developed and implemented urgently.
HMPPS
Swaleside (2022)
The IMB is concerned at the occasional failure to be invited to serious incidents and planned moves to the CSRU and would appreciate the necessity for this to be reiterated to all senior staff.
Governor / Director
Hewell (2022)
Increase momentum on culture change to ensure staff are curious, proactive and engaged and do not accept the unacceptable; identify and decisively address people or process issues that are blocking change. Pathway planning and key work is core to the change and should be given priority in all but the direst of staffing situations.
Governor / Director
In Progress
Haverigg (2022)
Thematic reviews carried out by members of the IMB open estate chairs’ group revealed differences between some prisons in a number of areas. The Board is concerned that apparent inconsistencies in these areas may cause confusion and, potentially, frustration when prisoners transfer between establishments: • application of the victim support levy • the number of prisoners being returned to closed …
HMPPS
Standford Hill (2023)
Will the Prison Service facilitate more formal sharing of best practice between Category D prisons?
HMPPS
Haverigg (2023)
the Board has not examined specific evidence to support or refute this feedback, but asks the Governor and senior managers to maintain careful and sustained oversight of this important area to ensure consistency.
Governor / Director
Huntercombe (2024)
When will the Prison Service ensure that all prisons follow the agreed procedures for all issues? The Board has reported on failures in prisoner property management and management of foreign national prisoners as two examples in this reporting year.
HMPPS
In Progress
Hull (2024)
How will the prison service put systems in place to resolve these issues? The Board note that these same concerns were raised in our 2021/22 and 2022/23 reports with limited progress continuing to be observed by the Board in this area.
HMPPS
In Progress
Cookham Wood (2024)
Will the Minister evaluate the potential for a better way of working in the English YOI estate?
Other
In Progress
Wandsworth (2025)
In the past year, the IMB was not always informed of major incidents, particularly deaths in custody. Can you assure us that you will put a process in place to rectify this?
Governor / Director
Wandsworth (2025)
In the light of the UN issued to the prison and the subsequent recommendations made under the Action Plan, what are your priorities as the newly appointed Governor?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2025)
We request that Care & Custody provide the IMB with a clear timeline and process for consulting with the IMB on the content and outcome of the review.
Other
Lowdham Grange (2025)
What is being done to ensure the mistakes and omissions highlighted in the recent Prevention of Future Deaths reports by the Coroner are not repeated?
Governor / Director
Channings Wood (2025)
What evidence can HMPPS point to that demonstrates that they do care and that things will indeed get better?
HMPPS
Werrington (2020)
Are there any positive changes for young people have been identified during the pandemic that can be implemented in the long term?
Governor / Director
Noted
Humber (2020)
The national leadership of the Prison Service has, in the opinion of the Board, hindered the ability of the prison to progress with the recovery process. They have been frustrated at the slow pace of recovery set out by national guidance from HMPPS, which has allowed little, if any room, for autonomy. The Board is of the opinion, in relation …
HMPPS
Hewell (2020)
The Board is often aware of a reliance on systems and processes in managing issues within Hewell, rather than a focus on robust problem solving and effective decision making. This tendency is demonstrated in the frequency with which ostensibly minor issues or concerns are allowed to escalate, with recourse to documentary systems – for example, the complaints or adjudication systems …
Governor / Director
Exeter (2020)
Will the Prison Service evaluate the impact of the COVID-19 pandemic on prison operation in order to learn lessons for the future and to retain those positive initiatives that have improved the lives and experiences for prisoners (for example, Purple Visits and streamed funeral services - paragraphs 5.5 and 7.4)?
HMPPS
In Progress
Bedford (2020)
Learn the lessons of the importance of family contact, both face to face and virtual.
HMPPS
Implemented
Yarl’s Wood (2021)
The Board recommends that, where practical, the centre gives the Board good notice of all subject multidisciplinary team meetings so that the Board has the opportunity to attend.
Governor / Director
Whitemoor (2021)
The Board strongly supports the establishment of the prison rehabilitation culture council and would encourage the Governor to continue the positive work she has begun to ensure that it is seen by prisoners as a significant force for the improvement of prison life in Whitemoor.
Governor / Director
Noted
Warren Hill (2021)
The Board also recognises that the prolonged lockdown has provided an opportunity to look at the regime at Warren Hill and hopes that the Governor will use this to implement positive changes.
Governor / Director
Grendon (2021)
Restrictions due to Covid-19 and project work notwithstanding, the Board looks forward to: rebuilding the culture and the sense of collective responsibility in the communities which has been affected across so many of the activities that Grendon was able to provide pre-pandemic (see 5.3.4, 7.1.3 and 7.1.5)
Governor / Director
Chelmsford (2021)
To support the Governor and staff in making the changes and improvements highlighted by Her Majesty's Inspectorate of Prisons’ inspection in August 2021, and those noted by us.
HMPPS
In Progress
Bristol (2021)
Please encourage HM Prison and Probation Service (HMPPS) and other visitors to the establishment to make contact with the Board. As independent volunteers carrying out a statutory role, we are a vital set of eyes and ears, and can provide valuable information and insights into the prison.
HMPPS
Nottingham (2022)
We hope that lessons learned during the lockdown period will be used to inform the organisation of the prison when the restrictions are lifted and that initiatives found to be beneficial can continue, so that the overall experience of prisoners is improved.
Governor / Director
In Progress
Grendon (2022)
Continued progress on rebuilding culture and ethos on the communities (7.1.3).
Governor / Director
Bedford (2022)
As far as we are aware there have been no attempts to evaluate the effectiveness of the assessment, care in custody and teamwork (ACCT) process to understand whether it has achieved (or failed) its objective of supporting those at risk of self-harm.
HMPPS
Lowdham Grange (2023)
To lead in the development of a strengthened working relationship between all prison staff and the members of the Board, which is based on mutual respect for their respective roles and which enables the IMB to fulfil its statutory duty.
Governor / Director
Durham (2023)
The Board understands that within the soon-to-be-implemented “Joint Care & Separation Units Standard Framework”, it is not mandatory for the prison to evidence compliance with the six principles of the framework. Why? (5.2.9)
HMPPS
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
Government policy should require a continuous care improvement programme is in place for each short-term holding facility. Such programmes should be collaboratively developed, well-documented, appropriately resourced, and transparently reported upon, adopting a quality improvement framework and integrating best practice from other settings.
Other
Maidstone (2024)
Improve relationship and collaboration with HOIE to ensure better communication with prisoners.
Governor / Director
Implemented
Health investigations(650)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xxi)
The Trust should conduct investigations into serious incidents according to the current guidelines and frame terms of reference so that they extend to examination of material policies and procedures.
london
Independent investigation: Sidney Waller, Manchester (2008) — Rec 11
The Trust should develop some good practice guidance on how to involve carers and relatives in investigations, based on the good practice that occurred in this case.
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 10
The Trust needs to consider how best to work with staff during future internal investigations. The following should be considered as basic best practice by providing: a full stenography service for the interview process; a period for witness review and amendment of transcriptions following an interview; an opportunity for witnesses …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 9
The Trust should ensure that any trends and patterns in relation to incidents, complaints or claims are examined for emerging themes and if there are performance issues, remedial action should be taken.
north_west
Independent investigation: Simon Breed, Wood Green (2004) — Rec R10
The trust reviews the management and organisation of all SUI reviews and board level inquiries to ensure adequate provision of time and appropriate staffing. This review process should consider how the trust can best learn from the reviews and implement their recommendations.
london
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Internal reviews of practice following major untoward events should be conducted by a manager with no direct line management responsibility for the case in question.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
Suffolk Health invites the members of the Inquiry Panel to reconvene, in private, within six months of publication of this report, to consider the responses, both official and unofficial, to the recommendations; and to report activity to Suffolk Health early in 1997.
east_of_england
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.5.a
Reviews Post-incident reviews and/or Serious Untoward Incident reviews/inquiries should include representation from all agencies involved with an individual patient. Current Serious Untoward Incident policies should be amended accordingly.
london
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.18.6
There should be an equally tight timetable for the response of the internal link contact in the Trust concerned to requests by the Investigation Manager. It is important for Trusts to understand the priority and weight of the independent investigation process, and to impress this on all staff involved. It …
south_west
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.18.1
In order to improve the investigation process, as soon as possible after an adverse health care event, there should be a swift internal review for the purpose of preserving all relevant documents and other evidence, and of identifying any urgent remedial action necessary for the protection of patients, staff or …
south_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 19
The Trust should ensure that when an internal investigation is completed, it leads to an action plan that can be monitored and that the outcomes are communicated to participants and others with a need to know in a timely way.
north_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 16
The Trust should use the findings of this Independent Investigation to inform its work on developing a more open and supportive culture to support high quality clinical practice. Proposed changes to the organisation and delivery of services should be fully discussed with partner agencies.
north_west
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 5
Senior clinical staff must be encouraged to seek the advice of their colleagues when they have a complex situation. Peer group and/or senior Multidisciplinary Team Meetings must be held to seek alternative approaches. Where cases are especially complex and/or risky and or intractable, senior clinical staff should engage in Multidisciplinary …
south_west
Independent investigation: Michael Kahan, Manchester (2008) — Rec 16
The Trust should ensure that investigations following serious untoward incidents follow the Trust policy. In particular the Trust should ensure that: staff and relatives are involved and informed in line with the principles of the policy; and that learning is disseminated to both staff and relatives.
north_west
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 31
The panel is concerned that many of the above conclusions and recommendations echo those made in other investigation reports, therefore consideration should be given to the use of such reports for training purposes. Additionally, the panel hopes that this report is widely disseminated across agencies.
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 5.i
We appreciate that there will be changes in how enquiries, following the homicide committed by an individual in contact with Mental Health Services, will be set up and arranged in the near future. However, any review of clinical decision-making, and the organisation, will be hampered if the senior staff use …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 1.iii
This process should be transparent to prevent a repeat of the lack of progress we noted following the internal inquiry and the Internal Inquiry report. However, it is important that this report should be widely shared in its entirety.
north_west
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 9
To review Trust procedures to ensure the dissemination of information to senior clinical staff of the conclusions and recommendations of internal and external reports investigating serious untoward events.
north_east_yorkshire
Independent investigation: Joseph Day, Folkestone (2001) — Rec 26
The East Kent Health Authority should ensure that there is a clear and consistent policy on the publication of independent investigation reports, with a presumption of public disclosure unless there are compelling reasons for confidentiality. This policy should also address the issue of anonymity for professionals, with a presumption against …
south_east
Independent investigation: Joseph Day, Folkestone (2001) — Rec 15
The East Kent Health Authority should ensure that independent investigations into serious incidents are conducted in a timely, transparent, and thorough manner, with appropriate involvement of families and carers. The findings and recommendations of such investigations should be widely disseminated to promote learning and prevent recurrence.
south_east
Independent investigation: Joan Smythe, Rainham (but SE Coast patient) (2002) — Rec 20.5.a
Post-incident reviews and/or Serious Untoward Incident reviews/inquiries should include representation from all agencies involved with an individual patient. Current Serious Untoward Incident policies should be amended accordingly.
south_east
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 23
that the Health Authority should ensure that this report is readily available to individual practitioners and people in West Berkshire.
south_east
Independent investigation: Denise Eckersley, Leeds (1999) — Rec 11
The Trust should ensure that, if there is an action plan that emerges from such a report, it is circulated to all those who may be involved in its implementation, for discussion and for action.
north_east_yorkshire
Independent investigation: Denise Eckersley, Leeds (1999) — Rec 7
The Trust should ensure, in implementing its serious untoward incident follow-up action procedure, that care is taken to investigate cases, at whatever level, as quickly as possible and, wherever possible, without waiting for the conclusion of external investigation and legal procedures. The Chief Executive’s discretion in this area should always …
north_east_yorkshire
Independent investigation: Carla Thompson, Merton (1998) — Rec 12
The Inquiry Panel recommends that the Department of Health should ensure that the findings and recommendations of this and other similar independent investigations are widely disseminated and actively implemented across all relevant health and social care organisations.
london
Independent investigation: Carla Thompson, Merton (1998) — Rec 10
The Inquiry Panel recommends that the Department of Health should promote a culture of 'no blame' and reflective practice within health and social services, to encourage open reporting of incidents and learning from mistakes, rather than a defensive approach.
london
Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006) — Rec 8
That there should be a review of the internal reporting in relation to serious untoward incidents. In particular, the Trust should seek to ensure that root cause analysis remains the focus of such internal investigations, which should be carried out robustly so as to ensure that failures are highlighted as …
north_east_yorkshire
Independent investigation: Vincent Douglas, Lewisham (2017) — Rec 1
Our team recommends that a Non-Executive Director be nominated to carry specific responsibility at Trust Board level to support dissemination of learning from incidents.
london
Independent investigation: Unknown, Unknown (2004) — Rec Recommendation One
It is recommended in accordance with best practice and to ensure that staff have the opportunity to check that the evidence they have given to internal reviews is accurate and reflects the issues that they wish to raise that all interviews undertaken for internal reviews are recorded and transcribed verbatim. …
london
Independent investigation: Trevor Spencer, Dagenham — Rec R4
The trust should ensure that there are systems in place to enable staff involved in a seriousuntoward incident to receive feedback from the subsequent investigation.
london
Independent investigation: Tracey Baker, Chard (2015) — Rec 14
Following a domestic homicide review (DHR), Somerset Partnership NHS Foundation Trust in partnership with SCCG should convene learning event for all the involved managers and practitioners.
south_west
Independent investigation: Tina Stevenson&2 babies, Hull (2005) — Rec 19.6
There should be a multidisciplinary peer review system developed, with the emphasis on a learning dialogue, when applications are not made by the Approved Mental Health Practitioner (AMHP – formerly ASW) for detention when in receipt of medical recommendations. Such reviews should be held by a senior mental health practitioner …
north_east_yorkshire
Independent investigation: Terry Wilson, Wewlyn Garden City (2006) — Rec 2
The Trust should review the ‘Learning from Adverse Events’ policy to ensure that its application has the intended effect of applying the ‘Being Open’ principles in relation to victims and relatives.
london
Independent investigation: Steven Janczuk, Arlesey, Beds (2006) — Rec 7
The Trust should coordinate SMART and targeted strategies to strengthen the support staff receive following serious untoward incidents, including participation in an external, independent investigation.
east_of_england
Independent investigation: Steven Janczuk, Arlesey, Beds (2006) — Rec 4
The Trust should continue to work on the cultural and organisational issues to increase the sustainability of the above recommendations. The Trust should therefore consider undertaking a safety culture audit to identify further areas for improvement within the next 12 months. Such an audit should take into account service-user, carer …
east_of_england
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 9
NHS England should engage with the National Police Chiefs’ Council to complete their review of the 2006 Memorandum of Understanding and provide interim guidance to the NHS in order to facilitate the early investigation of serious incidents in health care.
north_west
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 8
The Trust should ensure that the Board receives regular updates on the progress of all serious incident investigations. The roles of the Quality Committee and the Weekly Meetings of Harm in relation to learning and the tracking of progress need to be confirmed.
north_west
Independent investigation: Stephen O’Brien, Crewe (2016) — Rec 7
The Trust should, in the event of any future serious incident, take active steps to identify learning at an early stage. There should also be more formal and regular communication with other agencies, including the police, to ensure that all parties are aware of progress in relation to the management …
north_west
Independent investigation: Stephanie Barton, Boston (2007) — Rec 4
LPFT should demonstrate that it is a learning organisation by having robust arrangements in place to ensure a proper level of dissemination of the findings from internal Investigations.
midlands
Independent investigation: Shivani Taneja Kapoor, Northwood (2013) — Rec R8
The Trust medical director should seek advice from the GMC on whether a private psychiatrist should cooperate as fully as possible with a trust investigation.
london
Independent investigation: Sharon Wall, Gloucester — Rec 8.2
The first concerns the importance of ensuring that staff at Montpellier have the opportunity to see this report and discuss, if they wish, any points arising from it. We will arrange an opportunity to do this.
south_west
Independent investigation: Sharon Stokes, Exmouth (2007) — Rec 3.7.10.1.
The Devon Partnership NHS Trust needs to review its Serious Untoward Incident (SUI) policy to include: the introduction of reflective feedback sessions following serious incidents and near misses; the involvement of clinical teams in the development of recommendations; how learning and recommendations are to be shared across the Devon Partnership …
south_west
Independent investigation: Sandra Bainbridge, Belper (2013) — Rec 5
1. In order to maximise the learning taken from Ms Z’s fatal attack upon the victim, approaches to serious incidents should take account of the “bigger picture” of a serious incident. For example, investigating how a crisis has developed should be as a means to identifying learning which can generate …
midlands
Independent investigation: Ryan Merna, Poole — Rec 1
The Trust must ensure that all serious incident reports comply with all of the standards set out in the NHS England Serious Incident Framework so that: • root causes to incidents are clear in cases where they are identified; • appropriate learning can be identified and shared; • findings can …
south_west
Independent investigation: Robert Newby, Sticklepath (2007) — Rec 13
The Trust need to review the SUI Policy to include: the introduction of reflective feedback sessions following serious incidents and near misses; the involvement of clinical teams in the development of recommendations; how learning and recommendations are to be shared across the Trust; greater clarity about the involvement of the …
south_west
Independent investigation: Robert Lewis, Sutton (2010) — Rec Eleven
It is recommended that the Trust review and establish robust procedures following such catastrophic events to ensure senior leadership oversees their response. This must include support and understanding for the local team, ensure professional medical leadership, organisational learning and awareness of the impact on patients, families, carers and the organisation, …
london
Independent investigation: Robert Lewis, Sutton (2010) — Rec Four
It is recommended that for all serious incidents, such as a death of a patient, that results in the Trust setting up an internal review the family of that individual are given an opportunity to participate in the review process. The family should also have access to the final review …
london
Independent investigation: Robert CrookElsie Crook, Swindon (2007) — Rec Nine
The Trust must disseminate the findings of this Independent Investigation across the organisation as a case study to explore the implications of not producing contemporaneous records. These implications need to underline: the risks to the service user and their carers; the risks to the individual professional/worker; the risks to the …
south_west
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 14
The Trust need to review the Serious Untoward Incident (SUI) Policy to include: The introduction of reflective feedback sessions following serious incidents and near misses. The involvement of clinical teams in the development of recommendations. How learning and recommendations are to be shared across the Trust. Greater clarity about the …
south_west
Independent investigation: Philip Slater, Silsden (2017) — Rec 10
To facilitate and encourage interagency learning from this case, West Yorkshire Police should provide Bradford District Care NHS Foundation Trust and Airedale NHS Foundation Trust with their IMR’s findings and recommendations.
north_east_yorkshire
Scottish Fatal Accident Inquiries(5)
Edward Varey
Apr 2018
Daniel McSweeney
Dec 2018
Evan Bruce Cameron
Mar 2019
Dawn Marshall
Dec 2018
N
a. There should be greater communication and co-operation between NHST and NHS Grampian (“NHSG”) in relation to the care of patients who are resident in the geographical area of one authority and subject to treatment in a facility run by the other. b. NHSG should make greater efforts to co-operate in Significant Clinical Event Analysis (“SCEA”) inquiries in NHST where …
Jan 2018
Article 2 learning points(12)
— LP 22
We recommend that steps are taken at HMP Pentonville to share findings of future internal investigations, whether these investigations are formal or otherwise, with the relevant audience(s). We would encourage the use of face‐to‐face fora for this, rather than simply circulating investigation reports. This approach should help enhance the feeling …
The Governor
Accepted
— LP 1
If it has not already done so, HMP Whitemoor may wish to consider the benefits to be obtained from reviewing internal procedures and guidance for the management, recording and investigation under PSOs 1300, 2700 and 2750 of both prisoner on prisoner assaults and unexplained injuries. It may also be considered …
HMP Whitemoor
Accepted
— LP 7
I recommend that NOMS reviews the guidance to establishments about action following life-threatening incidents of self-harm to ensure that it makes clear that evidence must be preserved.
NOMS
— LP 17
The prison should develop a robust method for investigating serious untoward incidents using root cause analysis methodology.
HMP Altcourse
Partially Accepted
— LP 21
We recommend that following serious incidents, measures are taken at HMP Pentonville to ensure that support is provided, and information is actively disseminated, beyond the day of the incident itself. Responsibility for how this support is provided and how information is disseminated should be agreed at the post‐incident hot debrief …
The Governor
Accepted
— LP 15
We recommend the ongoing use of the record‐keeping audit tool being used on HMP Pentonville’s Healthcare unit, whilst ensuring that it continues to make a tangible difference and informs decision‐making, rather than being seen as a paper‐filling exercise. Showing staff exactly how it is making a difference should further encourage …
PPG
Accepted
— LP 14
In addition we recommend that the prison should take a proactive role in providing necessary written information so that, in general, the investigation is in the position of reviewing the documentation and deciding which of that supplied is relevant rather than trying to determine what documents may be available that …
HMPPS
Accepted
— LP 13
We recommend that a dedicated liaison officer be appointed for any Independent Investigation. The person appointed should report directly to the Governor for the duties performed in this role and should be allowed sufficient time away from normal duties to be able to perform to an acceptable standard and to …
HMPPS
Accepted
— LP 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
HMP Whitemoor
Accepted
— LP W
A clearer policy should be developed about the nature and extent of investigations which should take place following incidents of self-harm, so that prisons know when a local investigation within the prison is likely to be adequate, when an internal Prison Service investigation by the Area Manager is needed and …
HMPPS
— LP 12
We recommend that clearer guidance is produced on what kind of immediate internal inquiry should be undertaken following acts of serious self-harm, what evidence should be collated and retained and what form of action planning should be set in place as a result.
HMPPS
Partially Accepted
— LP 7
We recommend that Prison Officers E and F, Nurse 3 and the Night Orderly Officer, Mr M, should be commended for their diligence in seeking to save CR.
HMPPS
Accepted
Independent reviews(50)
Ockenden Review — Rec LAfL 14.9
Improving Management of Patient Safety Incidents Lessons from clinical incidents must inform delivery of the local multidisciplinary training plan.
Health & Social Care
Owens Review — Rec 33
That HMPPS and MoJ undertake a systematic review of all culture related recommendations (both in this review and others) to assess whether they are delivering the intended improvements. Any actions that are not achieving measurable progress should be refined, strengthened, or escalated.
Justice & Legal
Owens Review — Rec 32
That HMPPS communicate out to all staff action that has been undertaken as a result of this review, to showcase positive action and encourage improvements.
Justice & Legal
Owens Review — Rec 24
It is my belief that the need for a checklist will diminish if the other recommendations within this report are acted upon at pace. I therefore recommend that, HMPPS establish, with candour, the value of Governor checks. A better use of their time may be to concentrate on developing a …
Justice & Legal
Williams GNM Review — Rec 5.3
Those professional regulators that have a power to require information from registrants for the purposes of fitness to practise procedures should have this power modified to exclude reflective material. Registrants will still be expected to co-operate with their regulator in line with their code of practice and to be open …
Health & Social Care
Williams GNM Review — Rec 5.2
Both prosecuting authorities and professional regulators have been clear that they would be unlikely to use a healthcare professional's reflective material either for a criminal investigation or in considering a registrant's fitness to practise. The professional regulators should clarify their approach to reflective material through guidance.
Health & Social Care
Williams GNM Review — Rec 3.5
Signatories to the MoU should disseminate its contents in order to promote a greater understanding of legal issues among healthcare professionals and of healthcare issues (including systemic and human factors) among prosecuting authorities, the police and coroner services. This would help support the development of a "just culture" in healthcare, …
Health & Social Care
Jones: Patronising Disposition Review — Rec 21
The response of South Yorkshire Police to criticism over Hillsborough has, over the years, included several examples of what might be described as 'institutional defensiveness'. The force's repeated failure to fully and unequivocally accept the findings of independent inquiries and reviews has undoubtedly caused pain to the bereaved families. I …
Policing & Security
Jones: Patronising Disposition Review — Rec 11
An inquest should be an opportunity to learn the lessons of a death in order to help the living. A key tool for achieving this should be through the coroner's power to issue Prevention of Future Deaths (PFD) reports. I have been told by the legal representatives of the families …
Policing & Security
Jones: Patronising Disposition Review — Rec 6
On police ethics and ethos, I would echo the words of Theresa May, who as Home Secretary told the 2016 Police Federation Conference to: 'Remember Hillsborough. Let it be a touchstone for everything you do. Never forget that those who died in that disaster or the 27 years of hurt …
Policing & Security
Kerslake Birmingham Review — Rec 9
Birmingham City Council should redefine their partnership approach. They should do this by: a. producing with their partners a clear statement of their partnership values such as openness, transparency, learning, collaborating, safe and constructive challenge. These should be communicated and applied across the organisation and externally; b. having a shared …
Other
Morse Loan Charge Review — Rec 20
that, as campaigns on taxpayer issues such as the Loan Charge are likely to be a feature of debates in tax policy in future, HMRC should learn from the Loan Charge to better respond to such campaigns and communicate more effectively
Other
Levene Defence Reform Report — Rec 14
Key recommendation 14. The model depends on the right leadership and behaviours. The Department has failed in this regard in the past. Behaviours should be front and centre of, and embedded throughout, the implementation. The right example must be set from the top.
Other
Litchfield WCA Review Year 4 — Rec 35
Extend the feedback loop to ensure that learning is communicated to the HAP as well as to Decision Makers.
Employment & Work
Willis Commission on Nursing 2012 — Rec 26
The culture of healthcare provider organizations should be routinely assessed, building on ongoing work to develop and standardise a 'cultural barometer' that will help their boards ensure that practice settings are suitable learning environments.
Health & Social Care
Mental Health Taskforce 2016 — Rec 57
NHS Improvement and NHS England, with support from PHE, should identify what steps services should take to ensure that all deaths by suicide across NHS-funded mental health settings, including out-of-area placements, are learned from, to prevent repeat events. This should build on insights through learning from never events, serious incident …
Health & Social Care
Mental Health Taskforce 2016 — Rec 56
The Department of Health should ensure that the scope of the Healthcare Safety Investigation Branch includes deaths from all causes in inpatient mental health settings and that there is independent scrutiny of the quality of investigation, analysis of local and national trends, and evidence that learning is resulting in service …
Health & Social Care
Shape of Caring Review — Rec 26
HEE should forge greater links with the Academic Health Science Networks (AHSNs) to ensure that the workforce is able to adopt and use the latest research to inform and provide better patient care.
Health & Social Care
Winsor Review Part 1 — Rec 52
All police forces should take steps to learn from those police forces which have attained best practice in the area of the handling of poor performance and discipline, including in the training of supervisors who may have to use UPP procedures.
Policing & Security
Goldacre Review — Rec TRE 52
All best practice and teams should be identified and augmented There is a historic tendency for academic groups working on TREs and DAEs to be judged by the extent to which they are able to access data at all (reflecting historic challenges around access and IG); or the number of …
Health & Social Care
Goldacre Review — Rec TRE 48
There should be follow-up on all TRE projects resourced This should be regarded as a positive opportunity to share outputs, methods, code, insights and technical documentation for others to review, re use, or improve; and a chance to share barriers encountered for others. It is to be expected that some …
Health & Social Care
Goldacre Review — Rec TRE 44
All academic TREs must support, and should require, RAP and open working Modern, open, collaborative approaches to computational data science are the norm in other academic fields such as physics, structural genomics, structural biology, and more. Code sharing in the health data and electronic health records research community has fallen …
Health & Social Care
Goldacre Review — Rec Open 9
Make it “Okay to Ask” about access to publicly funded code The team heard from several interviewees that at present it is commonly regarded as provocative to ask for access to the code used to implement an analysis, especially in some parts of the academic community, despite general positive statements …
Health & Social Care
Goldacre Review — Rec S29
Build TRE capacity by taking a hands- on approach to the components of work common to all TREs. Avoid commissioning multiple closed, black box data projects from which little can be learned, or framing these as “experiments”. Experimentation is only powerful where it delivers openly shared working methods, code, outputs …
Health & Social Care
Freedom to Speak Up Review — Rec Principle 19
Primary Care: All principles in this report should apply with necessary adaptations in primary care.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 13
Transparency: All NHS organisations should be transparent in the way they exercise their responsibilities in relation to the raising of concerns, including the use of settlement agreements.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 8
Investigations: When a formal concern has been raised, there should be prompt, swift, proportionate, fair and blame-free investigations to establish the facts.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 6
Culture of reflective practice: There should be opportunities for all staff to engage in regular reflection of concerns in their work.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 5
Culture of valuing staff: Employers should show that they value staff who raise concerns, and celebrate the benefits for patients and the public from the improvements made in response to the issues identified.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 4
Culture of visible leadership: All employers of NHS staff should demonstrate, through visible leadership at all levels in the organisation, that they welcome and encourage the raising of concerns by staff.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 3
Culture free from bullying: Freedom to speak up about concerns depends on staff being able to work in a culture which is free from bullying and other oppressive behaviours.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 2
Culture of raising concerns: Raising concerns should be part of the normal routine business of any well led NHS organisation.
Health & Social Care
Freedom to Speak Up Review — Rec Principle 1
Culture of safety: Every organisation involved in providing NHS healthcare, should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns.
Health & Social Care
Harris Review: Deaths in Custody — Rec 104
All inquest findings, PFD reports and responses that relate to deaths in custody should be centrally collated and available for public search (subject to any necessary redaction).
Justice & Legal
Harris Review: Deaths in Custody — Rec 103
The Chief Coroner should be provided with sufficient resources to enable him to report on themes emerging from prevention of death reports involving deaths in custody.
Justice & Legal
Harris Review: Deaths in Custody — Rec 96
NOMS should consider each PPO recommendation and any Coroners’ jury finding and PFD reports individually, decide whether it applies only to the establishment where a death occurred or more widely across the estate, and then put in place an appropriate action plan in response to that recommendation (which may involve …
Justice & Legal
Harris Review: Deaths in Custody — Rec 25
Governors must commend every frontline member of staff who has actively implemented measures and made judgments that lead to the prevention of a self-inflicted death and that a record of every commendation and the action taken be shared with the Equality Rights and Decency Group, who must disseminate this across …
Justice & Legal
Harris Review: Deaths in Custody — Rec 22
Following each self-inflicted death in custody, the Minister for Prisons should personally phone the family of the prisoner who has died to express their condolences on behalf of the State and to promise that a full and thorough investigation will take place, and that any lessons from the death will …
Justice & Legal
Flanagan Review of Policing — Rec 28
Recognising that the Single Non-Emergency Number programme has acted as a catalyst for improved partnership working, the Home Office and CLG should ensure that learning from the programme is shared with all community safety partners and identify how to encourage and incentivise the mainstreaming of this approach into local operations. …
Policing & Security
Francis Inquiry (Mid Staffs 2010) — Rec 8
The Board should give priority to ensuring that any member of staff who raises an honestly held concern about the standard or safety of the provision of services to patients is supported and protected from any adverse consequences, and should foster a culture of openness and insight.
Health & Social Care
Laming Review (Baby P) — Rec 49
Ofsted should produce more regular reports, at six-monthly intervals, which summarise the lessons from Serious Case Reviews.
Other
Laming Review (Baby P) — Rec 48
Ofsted should share Serious Case Review executive summaries with the Association of Chief Police Officers, Primary Care Trusts and Strategic Health Authorities to promote learning.
Other
Laming Review (Baby P) — Rec 43
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to underline the importance of a high quality, publicly available executive summary which accurately represents the full report, contains the action plan in full, and includes the names of the Serious Case Review panel members.
Other
Laming Review (Baby P) — Rec 42
Ofsted should focus its evaluation of Serious Case Reviews on the depth of the learning a review has provided and the quality of recommendations it has made to protect children.
Other
Laming Review (Baby P) — Rec 41
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to ensure Serious Case Reviews focus on the effective learning of lessons and implementation of recommendations and the timely introduction of changes to protect children.
Other
Laming Review (Baby P) — Rec 40
The Department for Children, Schools and Families should revise the framework for Serious Case Reviews to ensure that the Serious Case Review panel chair has access to all of the relevant documents and staff they need to conduct a thorough and effective learning exercise.
Other
Laming Review (Baby P) — Rec 39
The Department for Children, Schools and Families should revise Working Together to Safeguard Children so that it is explicit that the formal purpose of Serious Case Reviews is to learn lessons for improving individual agencies, as well as for improving multi-agency working.
Other
Wood Review of LSCBs — Rec 29
To amend as appropriate the legislative framework to introduce this new model of inquiry.
Other
Wood Review of LSCBs — Rec 28
To ensure the new body has the capacity to commission and or carry out NSCIs.
Other
Wood Review of LSCBs — Rec 27
To ensure that this model is driven by proportionate LLIs, whose reports should be published and sent to the national body.
Other
LGO / SPSO decisions(5)
21-018-399 — Leeds City Council
Summary: We will not investigate Ms M’s complaint about the actions of a health visitor, who was providing a service on behalf of the Council. An investigation by the Local Government and Social Care Ombudsman is unlikely to add to the outcomes of previous investigations by other organisations.
LGO (Local Government & …
Other Categories
Apr 2022
25-002-918 — Greater London Authority
Summary: We will not investigate Mr X’s complaint that the Authority did not commission research into the aging process. This is because we cannot achieve the outcome Mr X wants.
LGO (Local Government & …
Other Categories
Jun 2025
201900021 — University of Glasgow
Ms C, a postgraduate student, complained that she had paid for classes and seminars which had been cancelled due to industrial action. We found that the University had taken appropriate steps to minimise the academic impact of the industrial action by giving students advance notice of the industrial action and …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
201808095 — University of Glasgow
Mr C was required to complete three school placements as part of his secondary teaching course. Mr C complained that the university failed to provide him with appropriate support during his course and that, after he was deemed to have failed, they did not follow their normal procedure. He was …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
22-004-281 — St James' Catholic High School, Cheadle
Summary: Miss Z complained the Independent Admissions Appeals Panel failed to properly consider her appeal for a place at the School for her child, Y. There was no fault in the way the Panel considered Miss Z’s appeal and reached its decision.
LGO (Local Government & …
Education
Not Upheld
Nov 2022
Domestic Homicide Reviews(582)— showing 50 strongest matches
Kingston upon Hull — recommendation 16
At the earliest opportunity the outcomes of this report will be shared with the Safeguarding Committee and members will cascade outcomes to key staff in the clinical areas.
Hull and East Yorkshire Hospital Trust
Portsmouth — recommendation 3
The author recommended the use of internal reviews for SCAS teams to learn from this incident. The author suggested receiving permission from family and staff and once typed seek authorisation from an Assistant Director to cascade learning to SCAS teams.
SCAS
South Central Ambulance Service …
Kent — recommendation 9
KCSP to ensure the MARAC Hub Manager is provided with this DHR, with a request it be considered during the development and implementation of new MARAC procedures
KCSP
Lincoln — recommendation Recommendation 5 i)
The Lincolnshire Domestic Abuse Partnership and Lincolnshire Safeguarding Children Partnership should engage with the Local Criminal Justice Board, to promote that they use the learning from the deaths of Bethany and Darren as a case study to raise awareness and understanding of the domestic abuse risks involved in these cases.
Lincolnshire Domestic Abuse Partnership | Lincolnshire …
Doncaster — recommendation 6
That South Yorkshire Police provide assurances and evidence to Safer Stronger Doncaster Partnership as to how they have embedded learning into practice in relation to DVDS applications and processes.
South Yorkshire Police
South Yorkshire Police
Doncaster — recommendation 4
That Safer Stronger Doncaster Partnership ensures that the learning from this case is used to inform the ongoing workstreams in responding to domestic abuse.
Safer Stronger Doncaster Partnership
West Lancashire — recommendation 28
NHS Integrated Care Board to share the lessons learned from the DHR with the individual practices across Lancashire and South Cumbria Primary Care Networks
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
West Lancashire — recommendation 10
WLCSP shares this learning with the Office of the Police and Crime Commissioner and health Sector commissioning services in Lancashire, including the NHS Integrated Care Board, so that they may explore the feasibility of developing an operating procedure to allow the co-location of these services within hospital based IDVA services
Office of the Police and Crime …
NHS Lancashire and South …
West Lancashire — recommendation 8
WLCSP to share the learning from this DHR review with Lancashire Constabulary and the Office of the Police and Crime Commissioner (OPCC) so that they may jointly consider the most appropriate Domestic Abuse Risk Assessment tool for improved risk identification
Lancashire Constabulary | Office of the …
Lancashire Constabulary
West Lancashire — recommendation 7
WLCSP to share this learning opportunity with the Lancashire Domestic Abuse Board and request they consider the findings of the Home Office Report with the aim of developing an assessment process that identifies any risk of victim suicide, i.e., where coercion and control (and according to the evidence – non-fatal …
West Lancashire Community Safety Partnership
West Lancashire — recommendation 5
To share this (action 4) learning opportunity with the pan-Lancashire DHR Task and Finish Group, in order to encourage services to consider the possible links between 'suicidal ideation' and Domestic Abuse as part of the intelligence gathering process to identify “victim suicides” who should be considered for the DHR process. …
West Lancashire Community Safety Partnership
Manchester — recommendation 2
That the Manchester CSP share the learning from this DHR with the Greater Manchester Bereavement Service; That the Manchester CSP share the learning from this DHR with the National Suicide Prevention Group in Wales and with the Mental Health Division within the BCUHB; That the Manchester CSP supports the recommendations …
Manchester Community Safety Partnership | Greater …
Norfolk — recommendation L
Norfolk Professional Standards Department produces a ‘Learning Times’ magazine of learning points such as this one. This learning point has been recommended for inclusion and circulation to all officers in the next edition. In this case the domestic abuse concern features on compact and a review of the missing circumstances …
Norfolk Constabulary
Norfolk Constabulary
Doncaster — recommendation 19.2.5
Learning to be disseminated to all those involved in this review within the Sheffield Diocese, ensuring any welfare needs are taken into consideration.
Sheffield Diocese
Doncaster — recommendation 19.2.4
The learning from this review to be disseminated to all staff involved in this case, including in their Supervision, to ensure that the lessons identified are embedded into practice.’
South Yorkshire Community Rehabilitation Company
Doncaster — recommendation 4
That the Safer Stronger Doncaster Partnership share the Domestic Homicide Review report with its substance misuse group to ensure that the learning is incorporated into practice, and the importance of professional curiosity highlighted.
Safer Stronger Doncaster Partnership
Derby — recommendation 1
All partners will ensure the multi-agency learning from the domestic homicide review QDCNH18 is shared and implemented across the workforce as part of continuing organisational engagement with the safeguarding agenda.
All partners
Tower Hamlets — recommendation 2
The Tower Hamlets CSP to write to the professional services company to share the findings of the DHR. In writing this letter, the Tower Hamlets CSP should express their disappointment at the professional services company’s failure to participate in the DHR and request they review their procedures to ensure they …
Tower Hamlets Community Safety Partnership
Tower Hamlets — recommendation 7.1.7
A Learning from Experience case study to be prepared and shared through reflective practice sessions. This will include a refresher in tenancy management for sublets; reporting compliance for violent & unexplained deaths; Safeguarding emphasis on professional curiosity with focus on debt, financial hardship and related vulnerabilities.
Metropolitan Thames Valley Housing
Swindon — recommendation 12
Book feedback session with the CA, listen to the case and get the CA to reflect on their actions.
CARE UK
Care UK
Milton Keynes — recommendation 5
Develop a culture of 'Professional Curiosity' within frontline practitioners and line managers, through on-going training and internal publicity
Milton Keynes Community Safety Partnership
Coventry — recommendation 7.1.2
Circulate the lessons from this case to all GPs in Coventry and Rugby CCG with a summary of the case history and discuss at the Face-to-Face GP training.
Coventry and Rugby Clinical Commissioning Group
NHS Coventry and Warwickshire …
Pembrokeshire — recommendation 11
Learning from this IMR be shared within the organisation to support the understanding of o Expected practice as it relates to the health and social care considerations of all patients and service users and o The principles of Social Services and Wellbeing (Wales) Act 2014 and Violence against Women, Domestic …
Welsh Ambulance Service NHS Trust
Welsh Ambulance Services NHS …
Hillingdon — recommendation 4.6.5c
Hillingdon CCG to share the findings and learning from this DHR with Hillingdon GP practices, Out of Hours Service and Hillingdon Urgent Care Centre.
Hillingdon ICB
Lancaster — recommendation 5
Pennine Lancashire Community Safety Partnership work with the Lancashire Criminal Justice Board who should use this case as an example to their partners about the importance of identifying non-compliance with safeguarding practice when undertaking investigations or considering the results of investigations.
Pennine Lancashire Community Safety Partnership | …
Somerset — recommendation 5
Circulate lessons learnt from DHRs regarding the need to clearly document social history during consultations.
Somerset Clinical Commissioning Group
NHS Somerset Clinical Commissioning …
Somerset — recommendation 1
Feedback and debrief to be offered to the General Practice prior to final publication.
Somerset Clinical Commissioning Group
NHS Somerset Clinical Commissioning …
Somerset — recommendation 7
The lessons from this Domestic Homicide Review should be reviewed and disseminated within the training commissioned for SCC ASC staff.
Somerset County Council Adult Social Care
Sefton — recommendation 3
Share learning from agency and Homicide Review.
Sefton Women’s and Children’s Aid
Sefton — recommendation 2
Share information from post incident review across Children and Family Network via governance arrangements.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Sefton — recommendation 3
SSCP to share the findings of this review as a case study with other agencies so as to ensure they recognise the long term impact of domestic abuse on children and understand the impact it can have upon them and their behaviours as they reach maturity.
Sefton Safer Communities Partnership
Haringey — recommendation 7
That all agencies involved in this review brief the employees who interacted with the victim or the perpetrator about the findings of this review (and NHSE to be specifically responsible for informing the Avenues Surgery of the outcome of this review before publication).
All agencies involved in this review …
Haringey — recommendation 6
That this review is disseminated to the Safeguarding Boards in Haringey for consideration within their local strategies and consideration be given to further dissemination within London or nationally, especially in light of the additional responsibilities for adult safeguarding contained within the Care Act, 2014.
Safeguarding Boards in Haringey
Basildon — recommendation 2
NHS England to share the findings from this Review, particularly drawing out the learning for General Practices, with those practices that were involved in the case.
NHS England
NHS England
Herefordshire — recommendation 2
Provide a Trust wide briefing on this case, detailing the observations, learning and recommendations from this individual management report. This will be communicated and Team managers will be directed to discuss in Team meetings.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Herefordshire — recommendation 1
Deliver a learning event to the teams involved in this episode of care delivery. This will provide staff with the learning from this review and give education on the actions.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Leicester
Share learning from Domestic Homicide Review lessons learnt from DHRs and SCRs at the joint safeguarding board and domestic violence delivery group conference on the 4th November 2014 aimed at frontline professionals, students and academics.
Leicester Safeguarding Adults Board
Kingston upon Thames — recommendation 46
To ensure that lessons learned from this Domestic Homicide review are considered in the development of the remit, terms and conditions of the Kingston Strategic Board for Domestic Violence.
Domestic Violence Strategic Board
Leeds — recommendation LYPFT4
Share the learning with team involved in this case.
Leeds and York Partnership NHS Trust
Leeds and York Partnership …
Leeds — recommendation LCH1
Feedback learning to team leaders at York St Health Practice – to include information sharing challenges & attendance at child protection meetings.
Leeds Community Health – York Street …
Cornwall — recommendation 12
That the learning from these domestic homicide reviews is routinely shared with children’s safeguarding teams to facilitate early joint approaches where children may be involved
NHS England
NHS England
Cornwall — recommendation 7
The DHR Panel recommend that a focused themed review of previous DHRs in Cornwall be undertaken to identify common themes and issues, from which focused learning and practice development can take place with local organisations. We make this recommendation in the context of there having been three previous DHRs in …
DASV & SOC Strategy Lead
Barnet — recommendation 22
That the Barnet Safer Communities Board ensure they receive confirmation from the agencies involved in this Review that the learning in this DHR has been disseminated to all staff within their service once the DHR has received approval by the Home Office and the date that dissemination completed. Also, that …
Barnet Safer Communities Board
Barnet — recommendation 5
The Home Office should forward copies of all DHRs involving a mental health component to the Secretary of State for Health & Social Care and the lead minister for mental health, for their consideration and to inform policy and decision making concerning community mental health and primary care service delivery.
Home Office
Home Office
Kensington and Chelsea — recommendation e
The Housing Operational Group to share domestic abuse best practice and learning with housing sales and legal conveyancing sectors
Housing Operational Group | VAWG Lead …
Kensington and Chelsea — recommendation e
The Children and Health Operational Group to identify GP surgeries and to share domestic abuse best practice and learning
Children and Health Operational Group
Bristol — recommendation 17.2.2
IMR findings to be cascaded where relevant to Child in Need team managers and social workers, via team meetings or briefing session
Leicester Social Care and Safeguarding Service
Bristol — recommendation 17.2.2
IMR findings to be cascaded where relevant with Child in Need Service heads of service and service managers, via senior management meetings.
Leicester Social Care and Safeguarding Service
Kirklees — recommendation 3
The learning from this case which includes depression being a potential marker for domestic abuse should be shared with all GP Practices in Kirklees.
GP Practice
Kirklees — recommendation 2
The authors of this IMR will contact the Practice and the individual GP who left the Practice on 1/4/17 to share the learning following review and approval from NHS England.
GP Practice
CJINI inspection reports(5)
The Handling of Complaints in the Criminal Justice System in Northern Ireland
Governance, The Criminal Justice System
Jul 2007
Telling Them Why – A Follow-Up Review of the inspection of the PPS giving of reasons for its decisions
Public Prosecution Service for Northern Ireland (PPS), Pros…
Oct 2015
Community Restorative Justice Ireland – A pre-accreditation inspection
Restorative Justice, Other Agencies and Organisations
May 2014
Resolve – A pre-accreditation inspection Report
Restorative Justice, Other Agencies and Organisations
Sep 2016
Review of PPS response to the review of related Sexual Abuse and Terrorism Cases (The Starmer Review)
Public Prosecution Service for Northern Ireland (PPS), Pros…
Oct 2017
CQC enforcement actions(10)
Warning Notice: East Sussex Healthcare NHS Trust
The Care Quality Commission rated East Sussex Healthcare NHS Trust as Inadequate overall following an unannounced inspection in March 2015. The trust was told it must make improvements in 12 main areas, including rebuilding effective relationships with staff, creating an …
Sep 2015
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued Gloucestershire Hospitals NHS Foundation Trust with a warning notice following an inspection of its surgical services. The inspection was undertaken in response to concerns received about the safety and quality of the services, including …
Cheltenham General Hospital and Gloucestershire R…
Oct 2022
Conditions Imposed: East of England Ambulance Service NHS Trust
The Care Quality Commission (CQC) used its enforcement powers at the East of England Ambulance Service NHS Trust, requiring it to overhaul its safeguarding processes and report back to CQC on issues it must address. This action followed an inspection …
Sep 2020
Warning Notice: Oxleas NHS Foundation Trust
The Care Quality Commission (CQC) served Oxleas NHS Foundation Trust with a warning notice, requiring immediate improvements to its mental health wards for older people. An inspection found out-of-date ligature risk assessments, a lack of clear mitigation for high-risk ligature …
Greenwich, Bromley, Bexley
Dec 2020
Fixed Penalty Notice: Bradford Teaching Hospitals NHS Foundation Trust
The Care Quality Commission issued a fixed penalty notice to Bradford Teaching Hospitals NHS Foundation Trust, fining them £1,250. This action was taken because the trust did not comply with the Duty of Candour, a regulation requiring providers to be …
Jan 2019
Warning Notice: Berkshire Healthcare NHS Foundation Trust
Following a review, the Care Quality Commission found that incidents concerning patient safety were not being reported quickly enough to the National Patient Safety Agency. The CQC required that the trust address this issue by 23 March, stating that if …
Mar 2011
Warning Notice: Southern Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Southern Health NHS Foundation Trust, requiring significant improvements to protect patients in its mental health and learning disability services. CQC found that the Trust did not operate effective governance arrangements …
Apr 2016
Warning Notice: Nottingham University Hospital NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Nottingham University Hospital NHS Trust following an inspection in June and July. CQC found areas where improvements were needed, particularly around leadership, risk management, governance, and culture. Concerns included a …
Sep 2021
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) published a report following an inspection of medical services at Kettering General Hospital NHS Foundation Trust in May due to concerns around patient falls. Following the inspection, the trust was issued with a warning notice …
Jul 2021
Warning Notice: Worcestershire Acute Hospitals NHS Trust
Following an inspection in November and December 2016, the Care Quality Commission issued a warning notice to Worcestershire Acute Hospitals NHS Trust. This action was taken because significant improvements were required in relation to staffing levels, governance, investigation of clinical …
Jun 2017