No person-centred care
Failure to ensure the provision of truly person-centred care that meets individual needs, preferences, and promotes dignity.
Source spread
Where this theme appears
This theme appears across 23 independent accountability sources, so the source mix matters as much as the headline total.
128 inquiry recs
237 PFD reports
180 committee recs
69 HSSIB recs
610 CQC actions
2 ICIBI recs
48 PPO recs
2 PHSO recs
75 IMB recs
35 IMB reports
4 Scottish FAIs
3 Article 2 learning points
2 detention investigation recs
320 DHR recs
215 PHSO decisions
60 LGO/SPSO decisions
18 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(128)— showing 50 strongest matches
37 — Unrestricted daily visiting
Recommendation: Truly unrestricted daily visiting, which does not exist at present, should be introduced as soon as possible.
Unknown
36 — Information booklet for patients
Recommendation: There should be a simple and attractive information booklet which should be given to each patient and his relatives on arrival specifying, among other things, the procedure for making suggestions and complaints.
Unknown
103 — General health examination alongside abuse examination
Recommendation: Where a child is being examined for evidence of sexual abuse a general examination of the child’s health should be carried out at the same time (17.40).
Unknown
87 — Role of prison Imams
Recommendation: The Muslim Adviser to the Prison Service should consider how the role of prison Imams can be expanded – without in any way compromising their religious role – so as to make them readier to assist with the non-religious needs …
Unknown
13 — Informing prisoners about progress of requests
Recommendation: The guidelines should require officers to keep prisoners informed of the progress of their requests, and if the request is refused, to notify prisoners of the reason for the refusal, unless security considerations or issues of confidentiality make that inappropriate.
Unknown
3 — Bereavement care
Recommendation: The National Bereavement Care Pathway for neonatal death should be implemented nationally and in all Trusts by 31 August 2027.
Gov response: And I agree with the report that, when the very worst happens and parents face bereavement, they need to be supported to the best of our ability. The report recommends the national bereavement care pathway …
Accepted
R100 — Person-centred day activities and supported employment
Recommendation: Trusts, private and 3rd sector care providers must ensure that person-centred day activities (including supported employment where appropriate) should be available and offered to all people with learning disabilities and autistic people. This should be monitored through Trust delivery plans.
No response yet
R90 — Regional standing committee of service users and families
Recommendation: A regional standing committee of people with learning disabilities and autistic people and their relatives should be established, to be consulted by the DoH and other bodies on services for learning disabilities and autistic people. This should be funded by …
No response yet
R86 — PCC information on quality of care standards
Recommendation: The PCC should support service users/families and provide information on what constitutes good quality care for people with learning disabilities and autistic people, and how to spot when care is falling short.
No response yet
R59 — CCTV explained in accessible format
Recommendation: All service users and their families should have the CCTV explained to them in easily understood language and with easy access materials, so that they are aware that it is for their protection, and so that they understand when it …
No response yet
R21 — Human rights officer in learning disability services
Recommendation: All providers of learning disability services should appoint a human rights officer, as seen in Sheffield Health Partnership University NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust. This role should support staff and monitor the progress of …
No response yet
R20 — Independent advocacy for service users and families
Recommendation: Properly trained independent advocates should be made available to service users and families to support effective communication with staff and for raising concerns and complaints. DoH/SPPG should specify the level of advocacy services required for people with learning disabilities in …
No response yet
R19 — Amend Quality Standards for shared decision-making
Recommendation: The 2006 Quality Standards for Health and Social Care should be amended to require HSC organisations to provide all people with learning disabilities, and if they lack capacity, their family or advocate, with the opportunity to share in all decision-making …
No response yet
R18 — Co-production processes and clinical audit
Recommendation: Specific processes rather than policies should be designed to ensure there is good communication with families and carers to ensure co-production takes place and is effective. Evidence of co-production should be an element of clinical audit of people’s healthcare records.
No response yet
R12 — Person-centred care plans with family involvement
Recommendation: Care plans must be live, person-centred documents. This requires joint ownership with people with learning disabilities and their families rather than simply professional records. While professionals necessarily lead assessments, families should be actively involved in identifying needs. Resulting care plans …
No response yet
R11 — Meaningful daily activities
Recommendation: Like anyone else, people with learning disabilities and autistic people require a variety of meaningful activities on a daily basis to enhance their quality of life. Every person should have an individualised activity schedule, including leisure activities and skill-building activities, …
No response yet
BRIS-9 — Develop kitemarking system for reliable internet health information guidance for public
Recommendation: The public should receive guidance on those sources of information about health and healthcare on the Internet which are reliable and of good quality: a kitemarking system should be developed.
Unknown
BRIS-8 — NHS Modernisation Agency to prioritise patient information quality and establish accreditation system
Recommendation: The NHS Modernisation Agency should make the improvement of the quality of information for patients a priority. In relation to the content and the dissemination of information for patients, the Agency should identify and promote good practice throughout the NHS. …
Unknown
BRIS-7 — Regularly update and pilot patient information materials with active patient involvement
Recommendation: Various modes of conveying information, whether leaflets, tapes, videos or CDs, should be regularly updated, and developed and piloted with the help of patients.
Unknown
BRIS-6 — Provide evidence-based patient information in a comprehensible summary format
Recommendation: Information should be based on the current available evidence and include a summary of the evidence and data, in a form which is comprehensible to patients.
Unknown
30 — Stop admissions from outside the inner catchment area
Recommendation: Admission of patients from outside Preston and its surrounding district (the inner catchment area) should cease as soon as possible.
Unknown
150 — Parents' presence and child's interests
Recommendation: The right of parents to be present throughout a Children’s Hearing should give way to the interests of the child when the child’s interests so require (18.32).
Unknown
149 — Inform parties of business meetings
Recommendation: The child and the child’s parent or guardian should be informed of any ‘business meeting’ of the Children’s Hearing and their position presented orally or in writing at that meeting (18.31).
Unknown
133 — Initial interview series not above four
Recommendation: An initial series of investigative interviews should usually not exceed four (17.75).
Unknown
131 — Maximum two interviews per child per week
Recommendation: In general a maximum of two investigative interviews per child per week should be appropriate and the frequency of interviews is a matter for regular review (17.73).
Unknown
106 — Child's choice of doctor's sex
Recommendation: A child should be able to choose whether the examination is conducted by a female or a male doctor (17.44).
Unknown
77 — Measures for mentally disordered prisoners on wings
Recommendation: The measures which should be taken to minimise the risk which a mentally disordered prisoner on ordinary location poses to staff and other inmates includes: • not placing such a prisoner in a shared cell • if such a prisoner …
Unknown
66 — Assigning personal officers to prisoners
Recommendation: Personal officers should be assigned to individual prisoners, not to a group of cells. They should be members of a small team, so that when a prisoner’s personal officer is not on duty, the prisoner can approach another member of …
Unknown
65 — Mandatory personal officer schemes
Recommendation: It should be mandatory for all establishments to have a personal officer scheme. That includes busy local prisons, although if time for personal officer work is limited, it should be used constructively.
Unknown
R52 — CCTV policies agreed with staff residents and families
Recommendation: Policies governing the use of CCTV should be agreed only after consultation with staff, residents and their families using the service.
No response yet
R51 — CCTV in non-public areas only in best interests
Recommendation: The installation of CCTV in non-public areas should be considered only where this will be in the best interests of the individual service user and following full consultation taking the views of relevant carers, service users (where possible) and relatives …
No response yet
R46 — Lived experience feedback via external agency
Recommendation: Where people with learning disabilities can participate, the provider should actively seek their lived experience feedback in relation to staff attitudes and behaviours on a quarterly basis through an external and independent agency (perhaps to be undertaken by the PCC), …
No response yet
R39 — Guidance on recording and presenting concerns
Recommendation: People with learning disabilities and autistic people and their families should be provided with a short description of how best to record and present concerns so as to be effective.
No response yet
R38 — Clear pathways for raising concerns
Recommendation: People with learning disabilities and autistic people and their families should be provided with clear, written information outlining the available pathways for raising concerns. This information should clearly distinguish between an enquiry, a concern and a complaint. Individuals should then …
No response yet
R37 — Human rights-based restrictive practices training
Recommendation: Education and training on the use of restrictive practices should be grounded in human rights principles and the dedicated human rights specialist appointed in accordance with Recommendation 21 (R21) should work with staff on this approach.
No response yet
R32 — Balanced performance measures including restrictive practices
Recommendation: HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from third-party providers. These measures should include: Trends in the use of restrictive practices; Trends of aggressive behaviour incidents, …
No response yet
R29 — Psychology input to reduce restrictive practices
Recommendation: All facilities providing residential services for people with learning disabilities and autistic people should provide sufficient psychology input for each patient, to obviate the need for restrictive practices in all but the most exceptional circumstances.
No response yet
R28 — Restraint Reduction Network principles
Recommendation: The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have adopted these principles, further action is needed to ensure the principles are fully embedded. These principles must be …
No response yet
R26 — Six-monthly financial accounts to families
Recommendation: Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) should be available to the service user concerned where possible and to the family where appropriate. Where appropriate …
No response yet
R25 — Accessible financial records
Recommendation: The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic people, carers and relatives.
No response yet
R22 — Easy Read documents
Recommendation: All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.
No response yet
R17 — Co-production training
Recommendation: Creating a co-produced care environment, where people with learning disabilities, families and professionals work collaboratively, requires a fundamental shift in practice. As well as organisational commitments, staff will need education and facilitation to transition to this way of working. Specific …
No response yet
R7 — Independent living skills focus
Recommendation: While patients remain in hospital pending resettlement, there should be a focus on enhancing their independent living skills, tailored to their physical and mental capacity.
No response yet
R5 — Named person for care plans
Recommendation: Any service user with a learning disability should have a named person (a key individual) responsible for their care plans and this person should be involved in and record the discussion with the family and the discussion with any relevant …
No response yet
R4 — Consultation before patient transfers
Recommendation: Prior to the decision to move a service user to a different facility there must be discussion with the staff regularly caring for them, the relevant multidisciplinary team (MDT), the person's family where practicable and the person themselves where possible, …
No response yet
BRIS-59 — Make communication skills education essential for all healthcare professionals
Recommendation: Education in communication skills must be an essential part of the education of all healthcare professionals. Communication skills include the ability to engage with patients on an emotional level, to listen, to assess how much information a patient wants to …
Unknown
BRIS-5 — Tailor patient information to individual needs, circumstances, and wishes
Recommendation: Information should be tailored to the needs, circumstances and wishes of the individual.
Unknown
BRIS-3 — Adopt patient-professional partnership model across all NHS healthcare settings
Recommendation: The notion of partnership between the healthcare professional and the patient, whereby the patient and the professional meet as equals with different expertise, must be adopted by healthcare professionals in all parts of the NHS, including healthcare professionals in hospitals.
Unknown
R11 — CDI severity awareness
Recommendation: Health Boards should ensure that patients, and relatives where appropriate, are made aware that CDI is a condition that can be life-threatening, particularly in the elderly. The consultant in charge of a patient’s care should ensure that the patient and, …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
4 — Reflection period for consent
Recommendation: We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. The GMC should monitor this as part of …
Gov response: Accept in principle Many key organisations, including the GMC, have taken steps to update their guidance, and to confirm that doctors should give patients sufficient time to consider their options before making a decision about …
Accepted in part
Prevention of Future Deaths reports(237)— showing 50 strongest matches
Ronald Sherlock
Concerns: Prisoners in the Older Prisoners Unit of HM Prison Norwich do not have appropriate access to speech and language therapists for assessing swallowing difficulties. This lack impacts their medical management, including recommendations for fluid, food intake, and soft diets.
Overdue
Rosa Anderson
Concerns: The patient was discharged without a summary, written information about her laparoscopic operation, contact telephone numbers for advice, or details on matters requiring urgent medical assistance.
Response (Aintree University Hospital): • The hospital confirmed a discharge advice sheet for laparoscopic procedures is in place and provided to relevant patients. • A separate patient information leaflet for hiatus hernia surgery, including … (AI summary)
Responded
Cynthia Fretwell
Concerns: The coroner noted concerns regarding the threshold for determining adequate telephone versus home consultations, the need for full mental capacity assessments when patients refuse treatment, and proper documentation of these discussions.
Response (Hama Medical Centre): • The practice updated its Mental Capacity Act 2005 Policy and its Telephone Consultation Protocol. • The practice discussed the Mental Capacity Act during medical meetings to update staff. • … (AI summary)
Responded
Sandra Wordingham
Concerns: The coroner highlighted that no medical opinion was sought for a resident remaining unconscious for a prolonged period after a suspected fit, delaying the diagnosis of an intracerebral haemorrhage. This approach places future residents with treatable conditions at risk.
Response (Springbank Nursing Home): • The nursing home dismissed one nurse and initiated disciplinary proceedings against another following an internal investigation. • The nursing home provided all nurses with the Nursing & Midwifery Council … (AI summary)
Responded
Adrian Johnson
Concerns: The coroner identified gaps in the assessment and management of tobacco withdrawal by healthcare professionals during initial prison screenings, which elevated the prisoner's vulnerability. Concerns also included insufficient healthcare input into ACCT reviews and inconsistent information sharing.
Response (HM Prison and Probation Service): • HM Prison and Probation Service (NOMS) and NHS England stated they would give further consideration to identifying tobacco withdrawal risks in screening processes and develop a care pathway, including … (AI summary)
Overdue
Pauline Meredith
Concerns: The coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Response (Browning Street Surgery): • The practice has formally instigated a programme of regular meetings to review all deaths in patients under 50 and will develop criteria to identify complex patients for discussion at … (AI summary)
Overdue
Ricky Anderson
Concerns: The coroner noted that Mr. Anderson's GP was not informed of his hospital admissions, leading to issues with medication supply. Furthermore, after an early discharge, there was over-reliance on family for information, and no care plan was established to assess his needs.
Overdue
Yousef Shokri-Gharab
Concerns: The coroner noted Mersey Care's informal patient leave policy is outdated, unreviewed since 2007, and inconsistent with current practice. It requires immediate updating to include multidisciplinary consensus, patient vulnerability considerations, and clear documentation.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team was tasked with ensuring all policies are reviewed and updated. • The policy identified by the coroner was reviewed and updated. • 50 policies were … (AI summary)
Responded
Maureen Leaver
Concerns: The coroner identified a lack of medical supervision for inpatients and inadequate systems for managing acutely ill elderly patients with complex conditions. There were also concerns about an insufficient understanding of legal duties under the Mental Health Act 1983 and Mental Capacity Act 2005 during patient transfers.
Overdue
Jack Lynn
Concerns: The coroner noted the absence of a medication communication sheet at Mr Lynn's home, which prevented reliable checks on medication, and that a 15-minute visit did not include a check on his safety or well-being.
Response (Nightingales Home Help Service): • The service stated it would encourage clients to use medication charts in their communication folders and advise that this is company policy for carers involved in medication services. • … (AI summary)
Responded
Andre Matei
Concerns: The coroner identified a lack of national guidance on the role of interpreters during labour, especially when interpreters are required in a theatre setting.
Response: • The Secretary of State for Health stated that the matter would be brought to the attention of the National Institute for Clinical Excellence (NICE). • The Secretary of State … (AI summary)
Responded
Phyllis Barnes
Concerns: The coroner noted a visiting GP did not fully appreciate the patient's serious post-operative condition, and a nurse-led telephone consultation appeared superficial. Additionally, there was no formal opportunity for the patient's daughter to relay her mother's condition to healthcare providers.
Overdue
Beryl French
Concerns: Concerns were raised regarding nursing staff's understanding of DNACPR forms and the completeness of information required for them. The report also identified insufficient End of Life Care planning to guide staff in supporting residents to die peacefully and with dignity.
Response (Life Style Care): • Life Style Care Plc has implemented a requirement for a GP-signed DNAR form to be present on a service user's file for it to be effective. • A new … (AI summary)
Responded
Frank Pope
Concerns: The coroner noted a lack of a clear 'back-up' process to ensure patients lacking capacity attend follow-up appointments, particularly when family members are not included in correspondence.
Response (Whittington Health NHS): • The Trust described its existing process for placing an alert on the patient administration system to copy appointment letters to family members or representatives for patients lacking capacity, upon … (AI summary)
Overdue
Keiran Toman
Concerns: The coroner noted psychiatric staff acquiescing to patient requests not to contact families, especially when patients lack insight and staff may lack training to assess capacity. This lack of family contact can isolate vulnerable patients, increase their risk, and decisions regarding family contact may not be reviewed often enough.
Overdue
Simon Haines
Concerns: Lack of clear protocols for signposting individuals struggling to accept decisions and insufficient re-signposting to support agencies creates a risk that others may not receive necessary help.
Overdue
John Thorpe
Concerns: The coroner noted concerns regarding the deceased's self-referral to mental health services instead of a direct referral, a lack of recorded follow-up, and that the patient's history and British National Formulary advice on anti-depressants were not adequately considered.
Overdue
Clare Cooper
Concerns: Concerns include inadequate GP assessment and documentation, a presumption of psychological issues without excluding organic causes, and a lack of systems for managing electrolyte abnormalities such as hyponatraemia. Additionally, referrals to eating disorder services lacked sufficient detail to prompt consideration of organic causes.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners outlined how its existing GP Curriculum provides guidance on sound recording systems and well-organised record-keeping. • The College detailed how its existing curriculum … (AI summary)
Response (Surrey Borders Partnership NHS): • The Trust revised its GP referral form and its internal triage form to improve the quality of information, prompt consideration of organic causes, and ensure comprehensive recording of physical … (AI summary)
Response (Royal College of Psychiatrist): • The Royal College of Psychiatrists has submitted a curriculum to the GMC for training standards for eating disorder specialists. • The Royal College of Psychiatrists has co-authored a revised … (AI summary)
Response (Woodlands Surgery): • Doctors agreed to improve documentation of consultations, robust assessment of symptoms, and routine vital sign monitoring, and will submit anonymised consultation notes for appraisal. • GPs will complete an … (AI summary)
Responded
Gillian Crossley
Concerns: The coroner noted inadequate documentation, insufficient observation and monitoring, and shortcomings in assessing and planning for Mrs. Crossley's discharge, compounded by poor communication among her care providers.
Overdue
James Clarke
Concerns: Inadequate overnight supervision meant carers did not check the patient for several hours, despite an expectation of constant presence. Furthermore, carers had received theoretical but no practical training for their specific duties.
Response (CQC): • The CQC carried out an unannounced inspection in May 2011, identifying shortfalls in the provider's risk assessment approach and requiring improvements. • The CQC will adopt new Health and … (AI summary)
Responded
Gloria Foster
Concerns: The coroner raises concerns about the absence of protocols for supporting staff during care provider closures, insufficient training on staff attitudes and team leader supervision, and inadequate management of communication channels after a closure.
Response (CQC): • The CQC stated it had clear guidelines in place for informing relevant agencies when a provider's registration was urgently cancelled. • The CQC stated it was undertaking a detailed … (AI summary)
Overdue
Nicholas Megginson
Concerns: Inconsistent advice was given to patients discharged post-surgery regarding the risks of venous thromboembolism and urgent clinical signs, both orally and in writing.
Overdue
Clive Turner
Concerns: The coroner noted a junior doctor's lack of awareness regarding prior pain relief from the ambulance service and hospital policies for overnight discharge. Concerns were also raised about the absence of senior clinicians for second opinions late at night.
Response (Welsh Ambulance Service NHS Trust): • The Trust developed a process for escalating calls with delayed ambulance responses to gain additional clinical assistance from NHS Direct Wales, which is scheduled to be in place by … (AI summary)
Responded
George Palmer
Concerns: The coroner highlighted issues with discharge follow-up mechanisms for patients transferring areas, specifically regarding continuity of support, and questioned the appropriateness of follow-up letters in cases of non-contact.
Response (Surrey and Borders Partnership NHS Trust): • The Trust reviewed processes for sharing information with new service providers for patients discharged due to relocation and reminded staff of relevant procedures. • The Trust stated it would … (AI summary)
Responded
Leonard Hudson
Concerns: The coroner identified a failure to follow the Trust's pressure ulcer policy, including inadequate incident reporting and risk identification. Further concerns related to insufficient record-keeping, confusion in patient care arrangements, and a lack of contingency for physiotherapy provision.
Overdue
Dorothy Clarkson
Concerns: The coroner noted issues with the procedure for providing food to residents requiring special preparation and assistance, and a lack of appropriate ongoing professional development training for nursing staff.
Overdue
Christopher Davies
Concerns: The coroner noted insufficient information shared with the patient and family about clozapine interactions with caffeine or smoking cessation, and the warning signs of toxicity. Regular reminders were suggested due to memory issues.
Overdue
John Andrews
Concerns: The coroner noted that Mr Andrews was discharged from hospital without his family being informed, leading to him arriving home alone with no immediate care in place, and subsequently falling.
Overdue
Chloe Siokos
Concerns: There was no framework for primary care staff to decide when an interpreter is required, and interpreters should be more readily available. Additionally, no system existed to flag relevant patient contexts to primary care staff.
Overdue
George Vickery
Concerns: The coroner noted that the decision to treat Mr. Vickery at a clinic instead of his home disregarded his GP's request. Southern Health's Integrated Community Services should formally consult with GPs regarding treatment location decisions.
Overdue
Mary Fenton
Concerns: The coroner identified a lack of out-of-hours cardiology consultant cover, echocardiogram facilities, and qualified staff for pacing wire procedures at Tameside Hospital. Further concerns included patient capacity and consent issues, critical drug shortages, and communication failures.
Response (Department of Health): • The Department of Health confirmed Isoprenaline injection is an unlicensed 'special' product in the UK. • The Department of Health was aware of problems with Isoprenaline availability and issues … (AI summary)
Response (Tameside Hospital): • The Trust implemented a 24/7 on-call rota for Consultant Cardiologists for emergency temporary pacing, which became operational on 10 November 2014. • A specialist nurse in safeguarding adults, MCA, … (AI summary)
Responded
Polly Carpenter
Concerns: The coroner identified that the RIO system lacked formal recording for both risk assessments and patient observation levels. This meant staff had limited knowledge of current risks, and robust care could not be audited.
Response (Devon Partnership NHS Trust): • Changes to the Supportive observation and engagement policy have been developed with nursing staff. • Revised documentation has been developed, which includes room for comments and associated guidelines for … (AI summary)
Responded
Barry Horrocks
Concerns: The prison environment was not adapted to Mr Horrocks' daily living needs, and no care providers within the prison system accepted responsibility for assisting with his intimate personal care requirements.
Overdue
Colin Ireland
Concerns: The coroner noted an inadequate discharge summary that failed to clarify medication status and the risks of late Friday discharges without assured weekend healthcare provision. Gaps in medication administration and venous thromboembolism risk assessments were also identified.
Overdue
Roseanne Cooke
Concerns: The coroner noted a lack of inpatient psychological support and confusion regarding outpatient referrals. Concerns were also raised about the Recovery Team's attendance at discharge meetings and insufficient communication of family concerns about the deceased's suicidal thoughts to the team.
Response (5 Borough Partnership NHS): • The Trust produced an action plan to improve the process for managing extended leave, including reviewing psychology provision and ensuring detailed electronic record entries. • The Borough's Leadership Team … (AI summary)
Responded
Mark Hancock
Concerns: The coroner noted poor and non-existent patient records, including a lack of documented risk assessments. Concerns were also raised about the absence of a policy for staff when a patient requires admission but a bed is unavailable.
Overdue
Elsie Mallalieu
Concerns: The patient's placement on an inappropriate ward, where staff lacked training for her high-flow oxygen and high workload impacted observations and record-keeping, raised concerns. Further issues included an inappropriate DNAR order, lack of escalation to higher care, and an unadministered antibiotic drip.
Response (Tameside Hospital NHS Trust): • Training has been provided to orthopaedic doctors regarding consultant involvement and documentation for patient transfers, and on appropriate patient movement from the Trauma Unit. A training schedule for Ward … (AI summary)
Responded
Tracey Bannister
Concerns: The coroner noted that patients undergoing ERCP surgery should be advised to contact the surgical department, not just their GP, if post-operative symptoms persist for more than 24 hours, as earlier medical attention could alter outcomes.
Response (Walsall Healthcare NHS Trust): • The Trust completed a Root Cause Analysis and took action regarding record keeping and patient observation. • The discharge information leaflet was revised to include clear instructions for patients … (AI summary)
Responded
Michael Harman
Concerns: The coroner noted insufficient follow-up after Mr Harman was found soiled and that indicators of his deteriorating condition did not trigger a review beyond the annual schedule. Handover notes also lacked specific welfare check requests.
Response (Centra Support1): • Centra Support completed an internal review of locality working practices. • Centra Support completed a review of welfare checks and the warden call response process. • Centra Support drew … (AI summary)
Responded
Amanda Hawkins
Concerns: The coroner noted increased vulnerability following changes in services and funding. Additionally, hospital appointments sent to the patient's home were not followed up due to her insufficient understanding to deal with correspondence and care co-ordinators not being informed of missed appointments.
Response (Dudley Walsall NHS Trust): • The Trust confirmed that outpatient letters from the North Community Recovery Service medical teams are now copied to the care coordinator. • A Working Group has been convened to … (AI summary)
Responded
Eve Cullen
Concerns: The coroner noted a failure to action and treat mental health referrals as urgent, identifying a lack of service-wide definitions for terms like 'urgent' and no agreed timeframes for referral action. This represented a lost opportunity for timely intervention.
Response (Worcestershire Health Care NHS Trust): • The Trust confirmed it had written to general practitioners in Redditch & Bromsgrove, outlining a protocol for urgent mental health referrals, including triage and face-to-face assessment within 24 hours … (AI summary)
Responded
Pauline Taylor
Concerns: Insufficient precision in the surgical term 'nephroureterectomy' led to clinician misunderstanding of the procedure's extent. Additionally, there was no designated case manager to monitor the patient's progress and coordinate care in a complex case.
Response (Department of Health): • Department of Health officials liaised with the British Association of Urological Surgeons (BAUS) to clarify the term "nephroureterectomy". • The Department reported that BAUS defined "nephroureterectomy" as the removal … (AI summary)
Response (Leeds Teaching Hospital): • The Trust sought and received clarification on the surgical term "nephroureterectomy" from the British Association of Urological Surgeons, subsequently emphasising this guidance to relevant staff and arranging its inclusion … (AI summary)
Responded
Christopher Watson
Concerns: The coroner raised concerns that files were closed after letters instructing recipients to ignore them if no action was needed were sent, without verifying receipt or comprehension. Direct contact was also not made with a vulnerable individual to ensure they understood available help or to assess their capacity.
Response (Norfolk County Council): • Norfolk County Council has ceased the practice of sending letters to individuals about whom concerns have been raised. • Staff have been instructed to make face-to-face contact with individuals … (AI summary)
Responded
Maurice Camfield
Concerns: The coroner noted that Mr. Camfield's agreed care plan, which stipulated one-to-one nursing care at all times, was not strictly followed by those involved in his treatment.
Overdue
Robert Watt
Concerns: The importance of clinic attendance was not explained, a cancellation letter was not sent, and urology referral documentation was absent. Junior doctors conducted specialist consultations, and a urologist did not review the patient despite suspected malignancy.
Overdue
Mary Hanson
Concerns: Concerns were raised regarding inadequate advice to the patient on surgical risks, poor documentation of consent discussions, and missing patient information leaflets. The 'best interests' assessment proforma was incomplete, and questions were raised about delegating this assessment to a staff nurse.
Overdue
Michael George
Concerns: The coroner identified senior management's apparent unawareness of previous PFD reports concerning physical health care on mental health wards, with insufficient progress on establishing domiciliary consultant physician visits. Concerns were also raised about inconsistent follow-up for glucose testing of patients on antipsychotics.
Response (South London and Maudsley NHS Trust): • The Trust established a Physical Health Committee chaired by two consultant psychiatrists. • Modified Early Warning Scores (MEWs) have been rolled out to improve the detection of deteriorating patients. … (AI summary)
Responded
Masoud Ghaderi
Concerns: The coroner noted inconsistent record-keeping of service user engagement and a lack of a designated staff member with overall responsibility for reviewing risk assessments to identify trends. Concerns were also raised about ward rounds relying on brief summaries rather than the full care record.
Response (Avon and Wiltshire NHS Trust): • The Trust rolled out local training on its Engagement and Observation Policy and conducted targeted training in inpatient suicide prevention. • Monthly spot audits of caseload supervision records will … (AI summary)
Overdue
Doreen England
Concerns: The coroner identified a lack of care plans for high-risk patients, insufficient staff knowledge and training regarding pressure sore prevention, and gaps in ward leadership and medical cover.
Response: • The case has been tabled for discussion at the Quality Surveillance Group. • NHS England is in communication with Birmingham Cross City CCG and will ensure the CQC is … (AI summary)
Overdue
Stephen Richardson
Concerns: The coroner raised concerns regarding the care on ward 225, where the deceased, who had Down Syndrome, was given inappropriate solid foods and drinks with unsuitable cups despite a risk of aspiration. Nursing staff frequently disregarded specific care requirements for his oral intake.
Response (University Hopsitals of North Midlands NHS Trust): • The Trust reviewed the deceased's medical records. • The Trust stated that instructions for the patient's diet and fluids were displayed at the bedside, and explained the rationale for … (AI summary)
Responded
Select committee recommendations(180)— showing 50 strongest matches
#134 —
Recommendation: We also heard that Youth Offending Services were able to communicate effectively with those they supervised. Justin Russell explained that speech and language therapists working in Youth Offending Services âare finding huge levels of communication need that have to be …
Response attribution not verified
#127 —
Recommendation: The Government should create incentives for low-level, âprolificâ offenders to engage with rehabilitation. It could find inspiration in the principles underpinning âIntegratedâ Community Service Order from Ireland, also addressing upfront the operational challenges identified in Ireland. Offenders should be given …
Response attribution not verified
#123 —
Recommendation: The rehabilitative needs of low-level, repeat offenders are not being met. Increasing the tariff of their punishment, be it in an individual case or through a revision of sentencing guidelines, is not the solutionâit would set people up to fail, …
Response attribution not verified
#119 —
Recommendation: When someone is sentenced to a community order, it is âvitalâ that they are assigned a peer mentor, we heard from Pavan Dhaliwal. She explained that someone who has previously been on probation can help an offender make the most …
Response attribution not verified
#118 —
Recommendation: We heard that mentors could encourage offenders engage with rehabilitation, whether they have been on probation themselves or are lay members of the public. Damian Hinds MP told us that âthere definitely is a roleâ for mentors. 230 He defined …
Response attribution not verified
#113 —
Recommendation: âThe concept of an integrated Community Service Order aligns better with principles of desistanceâ, Dr Guilfoyle argued. 219 He explained that âgiving a person the option to opt in and the ability to choose the type of personal development activity …
Response attribution not verified
#98 —
Recommendation: Rebecca Robson, for instance, told us about Womenâs Community Matters in Cumbria and the wide range of services the organisation offers: âWe run an eight-week group course called Womenâs First, which each week responds to a different pathway to reoffending, …
Response attribution not verified
#96 —
Recommendation: We heard about female offenders âfacing multiple disadvantage who may have different competing and intersecting needsâ. 182 Women in Prison also argued that âBlack, Asian, minoritised and migrant women experience âdouble disadvantageâ as a result of the combined impact of …
Response attribution not verified
#77 —
Recommendation: In the presence of a dual diagnosis, Niki Scordi argued that âservices being available for mental health, rather than addiction, is particularly importantâ. 133 Talking in generic terms about a woman on probation, she explained that âshe may know that …
Response attribution not verified
#70 —
Recommendation: Of all the reasons why community orders are a key sentencing option, one stands out: they can be tailored to the circumstances of individual offenders. In this chapter, we reflect on how best community orders can fit the individual. We …
Response attribution not verified
#48 —
Recommendation: The imposition of rehabilitative requirements should be guided by the individual circumstances of the case so as to ensure maximum efficiency of sentences. PSRs should provide the opportunity for rehabilitative needs to be assessed and for consent to be sought, …
Response attribution not verified
#47 —
Recommendation: The Probation Service, offenders , and their representatives should be given more opportunity to request Pre-Sentence Reports. Pre-Sentence Reports should be conducted in a way that makes offenders feel that they are being heard.
Response attribution not verified
#45 —
Recommendation: The number of PSRs prepared by the Probation Service, and the quality of these PSRs, have been declining dramatically in recent years. This is the outcome of an effort to save court time but comes at the expense of the …
Gov response: 162. We recognise the importance of PSRs as part of the sentencing process, including understanding whether an offender will engage with treatment requirements, and are working to improve the quantity and quality of advice. Our …
Position Not Stated
#44 —
Recommendation: Pre-Sentence Reports (PSRs) are an essential part of the sentencing process. They allow courts to tailor sentences to individual circumstances and give sentencers confidence that specific requirements are suitable and available in their area (see paragraph 67).
Gov response: 161. We agree. PSRs are probation’s assessment of the nature and causes of an offender’s behaviour, their rehabilitative needs, the risk they pose and to whom, as well as an independent recommendation of the sentencing …
Position Not Stated
#22 —
Recommendation: The Government should create incentives for low-level, âprolificâ offenders to engage with rehabilitation. It could find inspiration in the principles underpinning âIntegratedâ Community Service Order from Ireland, also addressing upfront the operational challenges identified in Ireland. Offenders should be given …
Response attribution not verified
#7 —
Recommendation: We welcome problem-solving courts, including specialised pilot âintensive supervision courtsâ. By taking a holistic approach and tailoring sentences to individual circumstances, and by holding offenders accountable for their progress through regular court hearings, we believe that problem-solving approaches can be …
Response attribution not verified
#23 —
Recommendation: Compensation schemes often require claimants to provide extensive evidence to demonstrate their eligibility for the scheme.56 However, the evidence we heard suggested that the evidential requirements on too many schemes have become overly burdensome and onerous for the claimants, and …
#17 —
Recommendation: We asked the departments whether they agree that there needs to be more co-design with victims on future schemes as early as possible. The Cabinet Office told us that co-design is essential for compensation schemes, because it believes it is …
#16 —
Recommendation: Kate Burt, Chief Executive of the Haemophilia Society, told us that Government could have avoided problems experienced by the Infected Blood Compensation Scheme if it had early engagement with affected communities – before the scheme launched.37 She said that the …
#3 —
Recommendation: We are concerned about the large volume of written evidence we received that highlighted people’s experience of multiple failings in the Department’s administration of the scheme. As well as highlighting delays, the people who contacted us described poor communication from …
Response attribution not verified
#44 — Ensure women's health hubs meet specific demographic needs, accounting for religious and cultural considerations.
Recommendation: Integrated care boards must ensure that their hubs meet the specific demographic needs of their populations, particularly accounting for religious and cultural considerations.
Response attribution not verified
#17 — Enforce informed consent and halt painful gynaecological procedures lacking adequate pain relief.
Recommendation: The NHS must do more to monitor and enforce protocols governing procedures such hysteroscopy, IUD fitting and cervical screening and ensure that they are underpinned by informed consent and are trauma-informed. A risk assessment that allows a patient to make …
Response attribution not verified
#16 — NHS fails patients during routine reproductive procedures, neglecting duty of care and pain management.
Recommendation: The NHS is failing many patients who undergo routine reproductive healthcare procedures such as hysteroscopy, IUD fitting and cervical screening. In too many cases, we find that a duty of care from gynaecologists and other medical practitioners is absent. Women …
Response attribution not verified
#56 — Address inappropriate assessment processes for disabled children’s parents and implement Law Commission proposals.
Recommendation: It is deeply concerning to hear that parents of disabled children are being treated with suspicion and undergoing inappropriate assessment processes when reaching out for help. The Department for Education must address this as an urgent priority and ensure that …
Response attribution not verified
#12 — Ensure FGM survivors are informed of interpretation rights and receive trained, culturally sensitive interpreters.
Recommendation: FGM Specialist Clinics and Women’s Health Hubs should ensure that women are informed of their right to have an interpreter. Those interpreters must be appropriately trained and sensitive to the cultural sensitivities around FGM. (Recommendation, Paragraph 37) Reconstructive surgery
Response attribution not verified
#11 — FGM survivors are often unaware of interpretation rights and face unsuitable interpreter services.
Recommendation: FGM survivors are not consistently being made aware that they are entitled to interpretation services. However, interpretation services that are available can be unsuitable and interpreters can lack the necessary 42 proficiency to advocate on behalf of survivors. This can …
Response attribution not verified
#1 — FGM survivors often lack awareness of long-term health complications and care needs
Recommendation: Survivors of female genital mutilation (FGM) experience profound physical, emotional and psychosexual consequences and require specialised care and support to manage these impacts. Despite this, survivors may not be aware that the health complications they experience are a consequence of …
Response attribution not verified
#64 — SEND families experience unsatisfactory interactions with local authority staff and EHC plans
Recommendation: Many children with SEND and their families continue to have unsatisfactory experiences when navigating the SEND system, particularly in their interactions with local authority staff. These challenges are often rooted in a failure to work empathetically in partnership with parents …
Response attribution not verified
#17 — Ensure active parental involvement in all SEND processes with independent advocacy and resources
Recommendation: Parents and carers must be actively and meaningfully involved in all processes that affect their child’s education, support, and overall wellbeing. This includes being fully informed and invited to participate in all relevant meetings where decisions about their child’s needs …
Response attribution not verified
#16 — Meaningful parental involvement is crucial for successful SEND system outcomes and trust
Recommendation: Parents and carers of children and young people with SEND often feel excluded from the processes that affect their children’s education and support. However, meaningful and collaborative parental involvement is essential to the success of the SEND system. When parents …
Response attribution not verified
#47 — Require Government to detail actions addressing complex health needs of women in custody
Recommendation: The Government should respond to this report setting out what action it is taking to address the complex health and wellbeing needs of the women it currently has in its custody. (Recommendation, Paragraph 212) 88
Response attribution not verified
#46 — System failing to meet complex health and wellbeing needs of women in prison
Recommendation: Women in prison often have acute and complex health needs, yet the system is failing to meet even their most basic requirements. We acknowledge the Government’s ambition to reduce the population in the female prison estate, and that change is …
Response attribution not verified
#40 — Young Offender Institutions routinely fail to meet minimum education hours for children
Recommendation: Article 28 of the United Nations Convention on the Rights of the Child affirms that all children have the right to education, including those in detention. Yet Young Offender Institutions are routinely failing to meet the statutory minimum of 15 …
Response attribution not verified
#37 — Publish updated Neurodiversity Action Plan detailing identification and support for prisoners
Recommendation: The Government must publish an update to the Neurodiversity Action Plan without further delay. It should include how they plan to systematically identify how many prisoners have neurodivergent needs, as well as how it aims to support them. (Recommendation, Paragraph …
Response attribution not verified
#36 — Lack of consistent data hinders support for neurodivergent prisoners in the system
Recommendation: It is unclear how the Government plans to support those with neurodivergent needs in the criminal justice system without having consistent and reliable data on how many neurodivergent prisoners there are. Furthermore, it is disappointing that those with neurodivergent needs, …
Response attribution not verified
#30 — Require Government to develop action plan for improving youth estate conditions, increasing time out of cell
Recommendation: The Government must respond to this report with an action plan as to how it plans to manage current conditions across the youth estate. For Young Offender Institutions, this should include what impact the introduction of 85 PAVA has had …
Response attribution not verified
#29 — Youth Custody Service and Young Offender Institutions fail children with excessive cell time
Recommendation: The Youth Custody Service, and in particular Young Offender Institutions, is clearly not working for children. Children should not be spending up to 23 hours a day in cell due to the failure of HMPPS to manage behaviour effectively. It …
Response attribution not verified
#26 — Require Government to produce plan for all prisoners to access full regime within three years
Recommendation: The Ministry of Justice must consider the benefits of giving remand prisoners access to all parts of the regime, should they choose to participate. In the event that this is not currently viable due to the prioritisation of courses for …
Response attribution not verified
#23 — Lack of rehabilitative support for remand prisoners increases reoffending risk
Recommendation: Many remand prisoners are convicted but released straight from court without any rehabilitative support. This means they are more likely to reoffend. We welcome impending change as part of the Sentencing Bill; however, we are concerned this will not go …
Response attribution not verified
#24 — Prioritise alliance models embedding VCFSE organisations in community mental health service design and delivery.
Recommendation: NHS England and Integrated Care Boards should prioritise the development of alliance models that embed voluntary, community, faith and social enterprise (VCFSE) organisations in the design and delivery of community mental health services. This should include clear expectations for co- …
Response attribution not verified
#19 — Reinstate annual physical health check target for SMI and embed health outcomes in Modern Service Framework.
Recommendation: NHS England should reinstate the annual physical health check target for people with severe mental illness (SMI) in operational planning guidance. This target has driven significant progress and remains essential for accountability, monitoring co-morbidities, and reducing preventable deaths. Building on …
Response attribution not verified
#16 — Publish clear guidance on key worker roles to ensure care coordination for service users.
Recommendation: In some areas, the emphasis on care coordination may have been lost through the rollout of the CMHF. We recommend that NHS England publish clear guidance on the role of key workers to ensure all service users have access to …
Response attribution not verified
#14 — Detail lived experience involvement and integration of MSF with wider support systems.
Recommendation: We would also like the Government to set out how people with lived experience will be involved in its development and how the MSF will be integrated with wider systems of support including those provided by the VCFSE sector and …
Response attribution not verified
#6 — Co-design new mental health care models with experts by experience
Recommendation: Our conclusions in this Chapter try to reflect what service users told us they wanted. This must be reflected in service design. As new models of care are commissioned and implemented, these must be co-designed with experts by experience to …
Response attribution not verified
#5 — Co-production and peer support essential for trusted and effective mental health services
Recommendation: Services shaped and delivered with, and by, people with lived experience of mental illness are more trusted, accessible, and effective. Meaningful co-production—where power is shared and lived experience is valued—is essential to high-quality care. Peer support, in particular, is a …
Response attribution not verified
#4 — Stigma and discrimination undermine equitable and culturally appropriate mental health services
Recommendation: Experiences of stigma, discrimination, and lack of culturally appropriate or personalised support were frequently reported, particularly by racialised communities, neurodivergent individuals, and those with disabilities. 74 Where care was described as high-quality, it was inclusive, responsive, and tailored to individual …
Response attribution not verified
#3 — Current mental health services fail to provide person-centred, holistic care
Recommendation: Service users, their families, carers and loved ones have been clear: high- quality care must be person-centred, responsive to the full range of needs individuals experience, and ensure involvement of their wider networks. Current services too often fall short—focusing narrowly …
Response attribution not verified
#2 — Lack of continuity of care fragments support for people with severe mental illness
Recommendation: Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, …
Response attribution not verified
#97 —
Recommendation: We heard about the best practices arising from the work of womenâs centres. Women in Prison told us that âapproaches based around prevention, early intervention and community-based support, are evidenced to be effective at reducing reoffending and support women in …
Response attribution not verified
#95 —
Recommendation: Nikki Scordi added that âwomen in particular worry about their children, whether they are with them or notâ. She explained that âoften, they are separated because of prison and cannot have them back, and that is a real concern for …
Response attribution not verified
HSSIB safety recommendations(69)— showing 50 strongest matches
Mental health: attempted suicide while under the care of community services
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Area of Improvement
Digital tools for online consultation in general practice
National healthcare organisations can improve patient safety by supporting software developers of online consultation tools to meaningfully involve patients and staff in software design to help better understand their needs. HSSIB suggests the following for integrated care boards Safety response …
Safety Observation
Digital tools for online consultation in general practice
National healthcare organisations can improve patient safety by considering how long-term condition management and proactive health promotion can be accomplished alongside the online consultation model of general practice, which may limit opportunities to provide holistic care to patients.
Safety Observation
Electronic patient record (EPR) systems – thematic review
Does your organisation have a process for carrying out effective equality impact assessments to consider the needs of specific patient and staff groups who may be users of the EPR system?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation ensure representative user engagement and involvement in all aspects of the configuration, integration and ongoing optimisation of EPR systems?
Learning Prompt
Patient care in temporary care environments
Does your organisation ensure that patients in temporary care environments are regularly engaged with to ensure that they have food, water, are comfortable, understand what is happening to them and what the plan is going forward?
Learning Prompt
Patient care in temporary care environments
Does your organisation provide information to patients about the use of temporary care environments and to inform them that any patient may be placed in one if there is a clinical need to provide a space for other patients?
Learning Prompt
Insulin: supporting safe self-administration in vulnerable patient groups in the community
HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation support staff to identify and code a person’s disabilities/impairments that may influence their competency to self-manage insulin, and ensure these are considered and adjusted for when deciding whether a person is competent?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
Does your organisation allocate specific resources to support patients, families and carers to develop competency to self-manage insulin, and ensure those resources are protected to empower and enable people?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation promote patient-centred care and facilitate self-care models that empower and enable patients, such as those with diabetes?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation proactively identify the varying needs of people with diabetes in its local population, and ensure these are met to enable their management of insulin?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation create the conditions for staff to empower and enable patients, their families and carers – through a person-centred approach – to self-manage insulin where appropriate?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
HSSIB recommends that NHS England/Department of Health and Social Care develops a tool for use in community settings to support the assessment of competency of patients, their families and carers to manage and administer insulin and care for people with …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a disability
HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is …
Safety Recommendation
Medication not given: discharge from an acute hospital to the community
How does your organisation ensure enough time is allocated to district nursing visits based on individual patient needs?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation consider family, carer or living arrangements when providing education on self-administration?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation ensure that education given to patients emphasises the importance of taking insulin and is appropriate and tailored to their individual needs?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation receive and consider information from families and carers to help avoid missed or delayed doses of time critical medications?
Learning Prompt
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Early exploration of adjustments that individual service users might need to engage in the triage and referral processes.
Area of Improvement
Recognition of the acutely ill infant
HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that any resources produced include examples of children and young people with non-white skin showing signs of serious illness.
Safety Recommendation
Care delivery within community mental health teams
NHS England has written to all mental health trusts in England to highlight the importance of taking a person-centred approach to psychosocial assessments and safety planning. The communication asks trusts to move away from risk assessment tools that stratify an …
Safety Action
Care delivery within community mental health teams
It may be beneficial for organisations to involve families in care planning and assessments, and that practitioners are appropriately trained in working with families.
Safety Observation
Care delivery within community mental health teams
It may be beneficial for mental health organisations to have a dedicated liaison officer who acts as a point of contact for both families and clinicians when navigating involvement in a patient’s care and decision making.
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
Clinical investigation booking systems failures: written communications in community languages — HSSIB
It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.
Safety Observation
Patients at risk of self-harm: continuous observation
Are staff supported to speak with or engage in an activity with the patient where appropriate?
Learning Prompt
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
Organisations can improve patient safety by listening to and communicating with patients, their families and carers, about the safety and wellbeing of people who have self-harmed and/or are expressing suicidal thoughts. It is important that this involvement starts from the …
Safety Observation
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
Organisations can improve patient safety by ensuring that a person centred approach to biopsychosocial assessment should be offered for all patients who have contact with mental health services, when a patient has an episode of self-harm or suicidal thinking, every …
Safety Observation
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
Organisations can improve patient safety by taking a person-centred approach to biopsychosocial assessments and safety planning and stop asking for evidence of risk assessment tools that stratify an individual’s risk of suicide or self-harm as high, medium, or low risk.
Safety Observation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
Organisations that provide mental health care can improve patient safety by adopting a comprehensive person-centred care approach that prioritises the individual needs, preferences and rights of each patient. This approach should ensure consistent access to meaningful therapeutic activities, actively involve …
Safety Observation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
HSSIB recommends that NHS England works with other stakeholders to define the term ‘therapeutic relationship’. This is to support building trust and compassionate relationships between staff and patients from admission to inpatient settings through to discharge, to improve patient outcomes.
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Providers of inpatient children and young people’s mental health services can improve patient safety by ensuring there is not a blanket approach to safeguarding mitigation measures based on a person’s age, and that mitigation measures are individualised and based on …
Safety Observation
Investigation report: Mental health inpatient settings - out of area placements
Mental health inpatient services can improve patient safety by offering advocacy to all mental health inpatients at the point of admission, and ensuring that the patient’s decision about whether or not to have an advocate is continually reviewed as their …
Safety Observation
Investigation report: Mental health inpatient settings - out of area placements
HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating …
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients …
Safety Observation
Sepsis: a patient with abdominal pain
There is limited understanding and awareness of processes to support family and carer involvement in clinical decision making about deterioration.
Area of Improvement
Sepsis: a patient with a urine infection
Lack of involvement of families to support the assessment of confusion in patients.
Area of Improvement
Clinical investigation booking systems failures: written communications in community languages
It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.
Safety Observation
Clinical investigation booking systems failures: written communications in community languages
It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
Safety Observation
Clinical investigation booking systems failures: written communications in community languages
It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
Safety Action
Clinical investigation booking systems failures: written communications in community languages
HSIB recommends that NHS England develops and implements a standard for healthcare providers on supplying written appointment information in languages other than English.
Safety Recommendation
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
Lack of involvement of families to support the assessment of confusion in patients.
Area of Improvement
Healthcare provision in prisons: continuity of care
Prison officers can improve patient safety by encouraging patients to engage with the healthcare team to discuss the reasons why they do not want to attend appointments. This will help to increase the appointment attendance rate.
Safety Observation
Healthcare provision in prisons: continuity of care
Prison healthcare departments can improve patient safety by increasing awareness and education for prisoners in terms of health, hygiene and the importance of engaging in their own healthcare. This will help patients to make informed decisions about whether to attend …
Safety Observation
Medication not given: administration of time critical medication in the emergency department
How does your organisation support patients to self-administer time critical medications, when appropriate?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and mitigate any mismatch between the expectations of patients, families, carers or staff and what the pathway can deliver in practice?
Learning Prompt
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHS England and NHS Improvement include in the Medication Safety Programme shared decision making and improved patient access to medication information across all sectors of care, to ensure a person-centred approach to safe and effective medicines …
Safety Recommendation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
a discussion with the patient on the problem of uncertainty, inherent in all diagnoses particularly in the absence of definitive diagnostic tests
Learning Prompt
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
It may be beneficial if the NHS England and NHS Improvement communications toolkit for local maternity teams to improve communications with women from Black, Asian and minority ethnic backgrounds is implemented in all healthcare services for pregnant women.
Safety Observation
NCEPOD recommendations(70)— showing 50 strongest matches
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
End of Life Care
Wording not shown. See the report on NCEPOD's website.
End of Life Care
End of Life Care
Wording not shown. See the report on NCEPOD's website.
End of Life Care
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
CQC inspection actions(610)— showing 50 strongest matches
Worthing Hospital
The trust should work towards reducing the number of times a patient is moved during their hospital stay.
Should Do
William Harvey Hospital
The trust should consider introducing education facilities for children staying on wards. Regulation 9(1): Person-centred care.
Should Do
William Harvey Hospital
The trust should ensure patient call bells are answered promptly.
Should Do
Westmorland General Hospital
The service should act to improve the assessment of women’s pain in light of their clinical condition.
Should Do
Westmorland General Hospital
The service should act to improve the assessment of women’s pain in light of their clinical condition and ensure all women receive pain relief in a timely manner.
Should Do
West Cumberland Hospital
The trust should continue to monitor its use of blanket restrictions on wards where patients may be inadvertently deprived of their liberty.Regulation13(5).
Should Do
West Cumberland Hospital
The trust must ensure that when a patient lacks mental capacity to make an informed decision, or give consent, staff must act in accordance with the requirements of the Mental Capacity Act 2005 and associated code of practice.Regulation13(1)(2)(3)(4)(d).
Must Do
Wavertree Bungalow
We recommend the provider assess the service using the principles of Right Support, Right Care, Right Culture, the CQC's guidance when providing support for autistic people and people with a learning disability.
Should Do
University Hospital of Hartlepool
The service should ensure that there are appropriate facilities and reasonable adjustments made for children and young people and their families who are being treated on adult wards to make them comfortable.
Should Do
The York Hospital
The service should ensure ED staff recognise or make reasonable adjustments to meet patient needs such as those with mental health issues or anxiety.
Should Do
The York Hospital
The service must ensure ED staff fully and accurately complete patients’ fluid and nutrition charts and offer patients drinks, especially long waiters, and those in recovery.
Must Do
The Princess Royal Hospital
The service should continue to improve the care provided to patients living with dementia which includes improving the environment.
Should Do
The Princess Royal Hospital
The service must provide care that meets the needs, and reflect the preferences, of patients.
Must Do
Sunderland Royal Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
Sunderland Royal Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
South Tyneside District Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
South Tyneside District Hospital
The trust should ensure patients living dementia have personalised plans of care which consider their individual needs and preferences.
Should Do
South Tyneside District Hospital
The trust must implement an effective system to ensure service users in established labour receive one to one care in line with best practice.
Must Do
Southport & Formby District General Hospital
The trust should continue to improve the involvement of patients and their families in decisions regarding care and treatment where DNACPR is considered.
Should Do
Scarborough Hospital
The service should ensure ED staff recognise or make reasonable adjustments to meet patient needs such as those with mental health issues or anxiety.
Should Do
Scarborough Hospital
The trust should ensure it meets the criteria for accessible information standard (AIS),
Should Do
Scarborough Hospital
The trust must ensure that attendance to patient ‘fundamental care needs’ are met, including getting enough help to wash or keep clean and to eat meals, as well as being able to get help from staff when needed.
Must Do
Scarborough Hospital
The service must ensure ED staff fully and accurately complete patients’ fluid and nutrition charts and offer patients drinks, especially long waiters, and those in recovery.
Must Do
Scarborough Hospital
The service must ensure staff do not place patients at higher risk such as those with IV access or allergies in inappropriate environments for their needs and observe them accordingly.
Must Do
Scarborough Hospital
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients, protects their privacy and dignity, and ensures staff can offer them emotional support.
Must Do
Scarborough Hospital
The trust must ensure they are delivering fundamental standards of care and patients receives safe and effective care that meet their needs.
Must Do
Salford Royal Hospital
The trust should ensure that all minority groups are included in service planning.
Should Do
Salford Royal Hospital
The service should ensure care and treatment is carried out with the informed consent of the patient and such consent is clearly recorded.
Should Do
Salford Royal Hospital
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should Do
Salford Royal Hospital
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should Do
Salford Royal Hospital
The service should ensure care and treatment is carried out with the informed consent of the patient and such consent is clearly recorded.
Should Do
Salford Royal Hospital
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should Do
Salford Royal Hospital
The service should ensure it takes action to encourage and improve the utilisation of ‘this is me’ documents or ‘hospital passports’.
Should Do
Salford Royal Hospital
The service must ensure patients are treated with dignity and respect and ensure the privacy for patients is maintained, particularly for those cared for on the corridor.
Must Do
Royal Victoria Infirmary
The service should ensure that information for patients is available in languages other than English and in alternative formats.
Should Do
Royal Victoria Infirmary
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferences.
Must Do
Royal Victoria Infirmary
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferencesRegulation9(1)(2).
Must Do
Royal Victoria Infirmary
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferencesRegulation9(1)(2).
Must Do
Royal Victoria Infirmary
The service must ensure that people who use the service receive person centred care and treatment that is appropriate, meets their needs and reflect their personal preferences.
Must Do
Royal Sussex County Hospital
The trust should work towards reducing the number of times a patient is moved during their hospital stay.
Should Do
Royal Sussex County Hospital
The trust must ensure the nutritional and hydration needs of patients are met. This includes establishing an effective system for patients to be supported by staff at mealtimes in order to maintain adequate nutrition and hydration. This also includes ensuring …
Must Do
Royal Shrewsbury Hospital
The service should continue to improve the care provided to patients living with dementia which includes improving the environment.
Should Do
Royal Shrewsbury Hospital
The service must provide care that meets the needs, and reflect the preferences, of patients.
Must Do
Royal Preston Hospital
The trust should consider sourcing comfortable chairs appropriate for patients with additional needs such as mobility or bariatric.
Should Do
Royal Preston Hospital
The trust should ensure that all patients with protected characteristics are supported such as availability of information in formats that patients understand.
Should Do
Rochdale Infirmary
The trust should ensure that all minority groups are included in service planning.
Should Do
Rochdale Infirmary
The service should ensure care and treatment is carried out with the informed consent of the patient and such consent is clearly recorded.
Should Do
Rochdale Infirmary
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should Do
Rochdale Infirmary
The service should ensure patients receive timely pain relief to ensure that care and treatment meets their needs.
Should Do
Rochdale Infirmary
The service should ensure care and treatment is carried out with the informed consent of the patient and such consent is clearly recorded.
Should Do
ICIBI immigration recommendations(2)
An inspection of asylum casework (August 2020 – May 2021)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
An inspection of asylum casework (June – October 2023)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
PPO death in custody recommendations(48)
The Governor
The Governor should ensure that the key worker scheme provides meaningful and ongoing support to all prisoners in line with national policy.
The Head of Healthcare
The Head of Healthcare should develop a food and fluid refusal policy to ensure that staff understand how they should manage prisoners who refuse food and fluids and that: a food and fluid refusal care plan is initiated promptly and …
The Head of Healthcare at Parc
The Head of Healthcare at Parc should ensure that CVOP meetings are clinically multidisciplinary, that effective care plans are created and implemented, and that the meetings are accurately minuted.
The Director of HMP Lowdham Grange
The Director might wish to consider how key-workers structure meetings with prisoners to focus on specific areas of concern.
The Governor of HMP The Mount
The Governor should ensure that the key worker scheme provides meaningful and ongoing support to all prisoners in line with national policy.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that applications for early release on compassionate grounds for prisoners with terminal illnesses are prioritised, and that a record is kept of action taken.
The Governor
there are regular wellbeing checks on prisoners subject to possible extradition or deportation to assess whether their risk to themselves has changed.
The Governor
staff understand the importance of having regular, meaningful conversations with prisoners to identify changes in appearance, behaviour or mood that may indicate increased risk;
The Governor
all prisoners receive regular wellbeing checks during the restricted pandemic regime, in line with the Exceptional Delivery Model and that these are recorded on NOMIS;
The Governor
The Governor should ensure that staff understand the importance of having meaningful conversations with prisoners where possible when carrying out welfare checks during the restricted regime.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are involved in their end-of-life care where practicably possible and that patient involvement in these discussions is recorded in the clinical notes.
The Head of Healthcare
The Head of Healthcare should set out a clear pain management pathway for prisoners and ensure staff follow it.
The Head of Healthcare
The Head of Healthcare should ensure that effective arrangements are in place to escalate concerns about patients at risk who do not cooperate with healthcare interventions and to respond appropriately following reports of overdose.
The Head of Healthcare at HMP Frankland
The Head of Healthcare should ensure that a medication review is undertaken when a patient does not request a repeat prescription of critical medications. This will ensure that the patients reasoning for non-concordance can be discussed and documented.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who present with persistent and challenging behaviours are assessed according to their level of risk and need, with consideration given to their most suitable location.
The Head of Healthcare
The Head of Healthcare should ensure that there are systems and processes in place to support ongoing clinical management of prisoners with challenging behaviour, which should include assessing mental capacity.
The Head of Healthcare
The Head of Healthcare should ensure that a prisoner’s perspective on detoxification is sought and recorded.
The Head of Healthcare and the Regional Manager for PPG
The Head of Healthcare and the Regional Manager for PPG should be assured that there is a refusal of care pathway in place which supports practitioners caring for patients who refuse treatment to a point of their self-neglect.
The Governor and Head of Healthcare
they should have been aware that Mr Malt had a DNACPR in place and respected his wishes.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff fully and clearly document conversations and decisions about patients who refuse medical treatment, including consideration of their mental capacity.
The Governor
The Governor should ensure that after a prisoner dies, prisoners who were close to him are informed of the death personally and offered appropriate, individual support.
The Head of Healthcare
The Head of Healthcare should review the process for managing and monitoring long-term conditions to ensure the development of meaningful patient-centred care plans.
The Governor
The Governor should ensure that staff are reminded not to use inappropriate or insensitive language towards prisoners, particularly, those being monitored under ACCT procedures.
The Governor of HMP Send
It would have been appropriate for prison staff to consider ROTL for Ms Chapman at the same time that they submitted her application for early release on compassionate grounds.
The Governor and Head of Healthcare
ensure that staff use appropriate interpretation services when discussing complex matters with prisoners with limited English language skills.
The Head of Healthcare
The Head of Healthcare should ensure that staff see prisoners at the agreed frequency, in line with their care or support plan.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that prisoners who are not taking or collecting their medication are identified and reviewed, and that prisoners choosing to isolate are able to safely collect and take their medication.
The Governor
The Governor should ensure that the ongoing review of the local Self-Isolation Strategy includes that isolating prisoners are properly supported, and that staff are trained in supporting prisoners towards ending self-isolation.
The Governor
The Governor should ensure that the review of the prison debt strategy considers care planning for known debtors and ensures that all agreed care plans are recorded on the prisoner’s record and therefore available for all staff to see.
The Governor and Head of Healthcare
healthcare staff review and document the mental state of a self-isolating prisoner at least once a week.
The Governor and Head of Healthcare
prison staff regularly review plans and ensure that any changes are recorded and actioned; and
The Governor and Head of Healthcare
plans for isolating prisoners contain detailed information about identified risks and agreed actions to reduce or end isolation,
The Director and Head of Healthcare at Parc
The Director and Head of Healthcare at Parc should liaise with the Medical Director for G4S and arrange an urgent meeting with the Chief Executive of Abertawe Bro Morgannwg University Health Board to ensure that full service provision for patients …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a robust process in place to ensure that applications for early compassionate release are properly monitored and completed without delay.
The Head of Healthcare
The Head of Healthcare should ensure that a formal mental capacity assessment is promptly completed and fully documented when there are concerns that a prisoner has declined medical advice or treatment.
The Head of Healthcare
The Head of Healthcare should review the current documentation process for DNACPR decisions and consider adopting the ReSPECT form.
The Head of Healthcare
The Head of Healthcare should remind staff to ensure that patients understand the risks of refusing medical tests and clearly document this in medical records.
The Director and Head of Healthcare of HMP Peterborough
The Director and Head of Healthcare should ensure that staff use approved interpretation services to communicate with non-English speaking prisoners when discussing confidential or complex matters.
The Head of Healthcare
The Head of Healthcare should ensure that if a patient refuses investigation of potential medical conditions, healthcare staff fully explore and document the reasons, and consider whether they need information or support to address any concerns.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should explore alternative options for meeting a prisoner’s care needs when they cannot be met on a standard wing.
The Head of Healthcare
The Head of Healthcare should ensure that personalised care plans with aims, planned interventions and monitoring, are in place for all patients with long-term health conditions.
The Governor of HMP Gartree
The Governor should ensure that staff understand the requirements for Release on Temporary Licence for medical purposes and a robust process is implemented to ensure applications are made when appropriate.
The Governor of HMP Gartree
The Governor should ensure that a robust process is in place to review Early Release on Compassionate Grounds (ERCG) refusals and resubmit applications where an individual’s health has deteriorated.
The Head of Healthcare
The Head of Healthcare should ensure that patients with multiple healthcare needs are discussed at the multi professional complex case conference meeting so that the MDT has full oversight of their complex care and multiple care needs.
The Head of Healthcare
The Head of Healthcare should ensure that the appropriate persons are being discussed in the multi professional complex case conference (MPCCC) so that the wider healthcare team have full oversight of their needs.
The Head of Healthcare
The Head of Healthcare to ensure that all patients who have life limiting conditions have an advanced care plan in place in accordance with the National Institute for Health and Care Excellence (NICE) guideline [NG142] for ‘end of life care …
The Governor of HMP Risley
bedwatch staff understand the need to treat prisoners’ visitors sensitively;
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who decline COVID-19 vaccinations are given the opportunity to reconsider their decision, and that healthcare staff discuss and record the reasons for the refusal.
PHSO ombudsman recommendations(2)
Discharge from mental health care: making it safe and patient-centred
NHS England should make sure that patients and their support network are active and valued partners in planning transitions of care and are empowered to give feedback, including through complaints.
Discharge from mental health care: making it safe and patient-centred
NHS England and Integrated Care Boards should make sure that people who are being discharged from mental health settings can choose a nominated person to be involved in discussions and decision-making around transitions of care.
IMB annual reports(35)
The Verne (2021)
HMP The Verne experienced a challenging year due to the COVID-19 pandemic, which caused a major outbreak, significant staff absences, and disruption to the prison regime, including education, work, and visits. Despite these challenges, the prison maintained a very safe environment with low violence, and the Board commended staff dedication and the strong ethos of mutual respect. Key concerns persist regarding the provision of 24-hour social and healthcare for the ageing population, slow progress on a proposed hospital unit, and the need for more purposeful activity.
PRISON
Key concerns
Stafford (2021)
This IMB annual report for HMP Stafford, a Category C training prison, covers a period significantly impacted by the Covid-19 pandemic. Key concerns include persistent poor medicines management, deteriorating staff-resident relationships, and the challenges of a highly restrictive regime compounded by a lack of in-cell telephony. Positive aspects noted were low violence and drug levels, successful vaccine rollout, and comprehensive in-cell activity provision.
PRISON
Key concerns
Coldingley (2021)
HMP Coldingley, a Category C training prison, faced significant challenges due to the Covid-19 pandemic, impacting regime, education, and work. The Board commends staff for maintaining a humane regime, containing Covid-19 outbreaks, and facilitating out-of-cell time. Key concerns include illicit items leading to violence, the lack of in-cell sanitation in older wings, and the poor state of the estate. The report highlights progress in areas like new accommodation pods and education initiatives but calls for addressing long-standing issues such as IPP prisoners and resettlement challenges.
PRISON
Key concerns
Dover Short Term Holding Facilities (2021)
The Dover Independent Monitoring Board raises urgent concerns about the continuing and worsening conditions at Tug Haven, Kent Intake Unit (KIU), and Frontier House. Facilities are severely overcrowded, leading to migrants, including vulnerable children, sleeping in unheated and unsanitary tents. Significant issues with undetected injuries, inadequate medical screening, and insufficient healthcare staffing are highlighted, along with staff demoralisation and safety incidents stemming from the challenging environment.
PRISON
Key concerns
Wayland (2023)
This report on HMP Wayland, based on a prisoner attitudes survey ending March 2023, highlights significant concerns across various aspects of prison life. Key issues include ineffective induction, poor staff-prisoner trust and communication, and a failure of the key worker scheme. Prisoners report feeling unsafe, lacking support for resettlement, and facing challenges with property, healthcare access, and the complaints system, alongside issues in education provision. The Board emphasizes a general lack of curiosity from management regarding these persistent problems, underscoring the need for fundamental improvements.
PRISON
Key concerns
Usk and Prescoed (2024)
HMP Usk and Prescoed are considered well-managed with positive outcomes for prisoners, who generally report feeling safe. Key strengths include high levels of purposeful activity, positive staff-prisoner relationships, and good healthcare, despite staffing concerns. However, the Board highlights issues such as the lack of IPP prisoner recategorisation, parole board delays, inadequate healthcare and probation staffing, and persistent property loss during transfers.
PRISON
Key concerns
Send (2024)
HMP Send is a closed prison for adult women and transgender prisoners, reporting a population of 247 at the end of March 2024, with an operational capacity of 255. The Board generally found staff efforts commendable in ensuring safety, noting reductions in self-harm and assaults compared to the previous year. Key concerns highlighted include the persistent lack of in-cell technology, staffing shortages affecting offender management and mental health services, and the continued detention of IPP prisoners.
PRISON
Key concerns
Whatton (2024)
HMP Whatton, a Category C training prison for sex offenders, had an average population of 849 during the reporting year. The Board observed generally positive prisoner-staff relationships, improvements in healthcare staffing, and good access to purposeful activity with 758 workspaces. However, key concerns include the unsuitability of B wing accommodation, long waits for specialist courses, the disproportionate number of IPP prisoners, and challenges in securing employment for sex offenders post-release.
PRISON
Key concerns
The Verne (2024)
HMP The Verne is a Category C training prison for sex offenders, holding 605 prisoners with an operational capacity of 608. The IMB noted generally good staff-prisoner relationships and effective healthcare, but raised significant concerns about the deplorable state of the healthcare building and kitchen roof. Key issues also include the barely functioning key worker scheme, a backlog in OASys assessments, and increased bullying linked to the prison's more moderate regime.
PRISON
Key concerns
Wayland (2024)
The IMB's latest survey at HMP Wayland shows a generally positive shift across many areas, including improved induction experiences, property handling, and healthcare complaint responses. However, significant challenges persist, particularly concerning staff's ability to provide effective support for personal issues and loneliness, which has worsened. Concerns also remain regarding cell decency, the pervasive availability of drugs, inadequate resettlement preparation, and the perceived unfairness of the complaints system, indicating much work is still needed.
PRISON
Key concerns
Wayland (2025)
The Wayland IMB's 2025 prisoner attitudes survey reveals a concerning decline in prisoner safety and trust, alongside persistent issues with basic decency standards in accommodation. While some improvements were noted in literacy support and property reception, significant challenges remain in staff-prisoner relationships, access to healthcare appointments, and the overall restrictiveness of the regime. The report highlights high levels of loneliness and a substantial drop in family visits, urging management to address these core concerns to improve prisoner welfare and prepare them for release.
PRISON
Key concerns
Heathrow and City airports Short Term Holding Facilities (2021)
The reporting period was significantly impacted by the Covid-19 pandemic, leading to concerns about infection control, longer detainee stays, and increased waiting times. Key issues included slow implementation of effective Covid-19 measures, inability for detainees to access personal medication, and inadequate hygiene and family facilities in some terminals. Despite these challenges, Detention Custody Officers were observed to be largely kind and courteous.
PRISON
Key concerns
East Sutton Park (2021)
HMP East Sutton Park is an open prison for women, commended by the Board for being a safe and well-run establishment during a period affected by the Covid-19 pandemic. Key strengths include strong healthcare provision, effective resettlement preparation with good accommodation and employment outcomes, and valuable educational programmes. Challenges persist with ensuring prisoners are transferred with sufficient time to serve, effectively utilizing the IEP scheme for disruptive behaviour, and managing weekend medication administration.
PRISON
Key concerns
Grendon (2021)
HMP Grendon demonstrated a safe environment in 2021 with improvements across several safety indicators including self-harm, assaults, and ACCTs, despite ongoing Covid-19 restrictions and fire safety works. The Board commended improvements in diversity and inclusion, healthcare access, and vaccine rollout. However, significant concerns remain regarding the persistent issues with the night sanitation system, the loss of community ethos, and the impact of fire safety project delays on therapeutic capacity. The lack of in-cell telephony and data on cell bell response times also pose ongoing challenges.
PRISON
Key concerns
Charter Flight Monitoring Team (CFMT) (2021)
The IMB Charter Flight Monitoring Team (CFMT) report for 2021 found that while many returnees were treated with respect and efforts were made for infection control, significant concerns persisted regarding the fairness and humanity of the removal process. Key issues included prolonged in-vehicle confinement for returnees, inconsistent use of restraints, and communication gaps due to a lack of interpreters. The report also highlighted deficiencies in the provision of welfare items and information, especially for vulnerable individuals, and repeated recommendations on issues like distant airports and privacy on flights.
PRISON
Key concerns
London Heathrow and City Airports (2022)
This IMB report for Heathrow and City Airports' Short-Term Holding Facilities covers February 2021 to January 2022. It highlights ongoing concerns regarding extended detention times, inadequate facilities—especially for families in Terminal 5—and a critical lack of Wi-Fi and consistent access to medication across all sites. Despite these issues, the Board notes positive developments such as improved access to medical support at Heathrow, updated religious provisions, and generally respectful interactions from staff, while urging further improvements in staffing, infrastructure, and detainee welfare.
PRISON
Key concerns
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
This IMB annual report for Scotland and Northern Ireland's Short-Term Holding Facilities (STHFs) highlights significant welfare concerns for the reporting year ending January 2022. Key issues include widespread disability access shortfalls across the estate, an unacceptable increase in extended detentions in unsuitable airport holding rooms, and the unresolved problem of managing detainees' prescription medication. The Board also notes long-overdue facility upgrades at Larne House and inadequate ventilation systems, particularly concerning Covid-19 risks.
PRISON
Key concerns
Dungavel House IRC (2021)
Dungavel IRC was well-managed by both GEO and Mitie throughout 2021 despite COVID-19 challenges, treating residents fairly and safely. Healthcare provision was good, and a relaxed regime with ample activities was maintained due to low resident numbers. Key concerns included IMB member recruitment, high CSU temperatures, the need for a disability officer, and unresolved issues like staff negotiation training and parking.
IRC
Key concerns
Stafford (2024)
HMP Stafford, a Category C training prison for men convicted of sexual offenses, is largely perceived as safe and calm, with commendations for staff and positive developments in medicines management. However, the Board raised significant concerns over persistent legionella issues and inadequate shower facilities, ongoing staff shortages impacting regime, and the unaddressed plight of IPP prisoners. Challenges also include the poor state of healthcare facilities, insufficient neurodiversity support funding, and difficulties in Board member recruitment.
PRISON
Key concerns
Preston (2024)
HMP/YOI Preston is a Category B local prison for men, with an average population of 670 and an operational capacity of 680. The prison recorded four deaths in custody and opened 736 ACCT cases, reflecting high self-harm rates, while violence remained an issue. Positive developments include increased time out of cell and a fully operational key worker scheme. However, key concerns include the poor state of the Victorian estate, inadequate kitchen maintenance, and gaps in resettlement support from external agencies, especially for remand prisoners.
PRISON
Key concerns
Rye Hill (2024)
HMP Rye Hill is a privately run Category B training prison for men convicted of sexual offences, currently transitioning to become an all-Category C facility, holding 662 prisoners against an operational capacity of 625. The report highlights improvements in education and employment, good staff-prisoner relationships, and a new neurodiversity team, but raises significant concerns about the systemic injustice of IPP sentences, protracted compassionate release processes, and persistent issues with property transfers and inter-prison moves.
PRISON
Key concerns
Warren Hill (2024)
HMP Warren Hill is a Category C prison maintaining a safe and humane environment with effective safety measures and good staff-prisoner relationships. Key concerns include the outsourced food provision, the impact of Ministerial intervention on prisoner progression and ROTL, and the need for investment in the estate and digital education. The IMB highlights improvements in key worker delivery, healthcare, and resettlement support, advocating for on-site kitchen facilities and reinstatement of ROTL to further enhance prisoner experience and preparation for release.
PRISON
Key concerns
Stocken (2024)
HMP Stocken is a Category C training prison with an operational capacity of 1,071, generally providing a safe and humane environment. The report highlights improvements in education and vocational training and increased staff recruitment and retention, but raises concerns about prolonged mental health transfer delays, property transfer issues, and the prison's unfunded role in direct resettlement. The Board also notes the need for refurbishment in older parts of the estate and long waiting times for accredited programmes.
PRISON
Key concerns
Thameside (2024)
HMP Thameside is a privately operated local Category B/C prison for adult male prisoners, often occupied close to its operational capacity of 1232, with a 75% remand population. The IMB reports persistent concerns regarding healthcare provision, increasing delays in mental health transfers, and issues with the maintenance of the estate including lifts and in-cell technology. While some improvements have been noted in areas like reception, significant challenges remain in staffing, violence reduction, and ensuring fair and humane treatment, particularly concerning property management and the disproportionate disciplining of Black/mixed race prisoners.
PRISON
Key concerns
Peterborough (men) (2024)
HMP/YOI Peterborough (Men) is a category B remand, local and reception/resettlement prison run by Sodexo Justice Services, with an operational capacity of 944. The reporting year was challenging due to population pressures, staff shortages, and management changes, resulting in a restricted regime and impacted prisoner morale. Despite efforts to maintain safety, concerns persist regarding purposeful activity, healthcare provision, and the quality of key work.
PRISON
Key concerns
Peterborough (women) (2024)
HMP/YOI Peterborough (Women) struggled significantly with a lack of decent regime and severe staffing shortages during the reporting year, impacting prisoner morale and increasing violence. While management of self-harm and staff-prisoner relations remained commendable, issues with the new healthcare provider regarding medication, complaints, and mental health waiting lists persisted. The Board expressed strong concerns about the slow progress on mental health legislation and the critical need for improved purposeful activity and resettlement accommodation for women.
PRISON
Key concerns
Sudbury (2024)
HMP/YOI Sudbury, an open Category D resettlement prison, ended its reporting year with 507 prisoners. The report notes no deaths in custody and low self-harm incidents but highlights recurring concerns regarding the poor standard of dormitory accommodation and significant issues with prisoner property loss on transfer. While commendations are made for effective resettlement programs and improved complaint responses, the Board calls for improvements in digital connectivity, broader activity provision, and more consistent staff contact, particularly for new arrivals.
PRISON
Key concerns
Portland (2024)
HMP/YOI Portland continued to face significant challenges during the reporting year, primarily due to staff shortages and overcrowding, which impacted regime delivery and the reintroduction of double cells. Violence and self-harm incidents increased substantially, although measures to improve safety and reduce illicit substances showed some positive results. Healthcare staffing improved, but mental health provision and transfers remained a concern, while resettlement efforts were severely strained by poorly implemented early release schemes.
PRISON
Key concerns
Send (2025)
HMP Send, a closed prison for adult women, managed a population of 245 prisoners against an operational capacity of 255. The Board commended staff efforts in ensuring safety and positive relationships, noting improvements in complaint handling. However, the report highlighted significant increases in self-harm, assaults, and use of force incidents, along with persistent concerns regarding the adequacy of mental health provision for complex needs prisoners, the lack of digital technology access, and issues with inter-prison transfers.
PRISON
Key concerns
Erlestoke (2021)
HMP Erlestoke generally maintained a safe and humane environment during the reporting year ending March 2021, despite the challenges of Covid-19. Key improvements included a significant reduction in violence, commendable healthcare management of a Covid-19 outbreak, and improved resettlement planning. However, concerns remain regarding a troubling increase in self-harm, inadequate provision for prisoners with complex needs and IPP sentences, estates issues, and the impact of regime restrictions on purposeful activity.
PRISON
Key concerns
Cardiff (2021)
HMP Cardiff maintained a reasonably safe and humane environment during the reporting year despite significant Covid-19 challenges. Self-harm and use of force incidents reduced, and healthcare staffing improved, but a restrictive regime impacted prisoner wellbeing and purposeful activity. Key concerns include a lack of mental health transfer beds, inadequate accommodation on release, and ongoing issues with prison infrastructure and perceived discrimination against BAME prisoners.
PRISON
Key concerns
Moorland (2022)
HMP/YOI Moorland, a Category C resettlement prison, reported a population of 915 against a reduced operational capacity of 964 for the year ending February 2022. The report noted positive trends with reduced self-harm and violence incidents but highlighted significant concerns regarding the treatment and progression of IPP prisoners and persistent delays in mental health transfers. Staffing shortages affected key worker provision and programme delivery, while long waiting times for dental care were also an issue.
PRISON
Key concerns
Rye Hill (2022)
HMP Rye Hill adapted its regime throughout the year due to ongoing Covid-19 restrictions, maintaining a safe and secure environment with reductions in self-harm and violence. The Board commends the prison's communication strategy and staff efforts, but highlights significant concerns regarding IPP prisoner progression, end-of-life care procedures, and the lack of specialist resettlement support for sex offenders released directly from the prison. Healthcare provision faces challenges with a pending change of provider and long waiting times for care assessments.
PRISON
Key concerns
North Sea Camp (2022)
HMP North Sea Camp is an open Category D male resettlement prison. This report covers the period from March 2021 to February 2022, during which the prison managed a return to a more normal regime following Covid-19 restrictions, demonstrating strong rehabilitative efforts and good healthcare provision. Key concerns persist regarding end-of-life care, inadequate accommodation and accessibility for disabled prisoners, delays in offender management, and issues with contracted maintenance and property transfers.
PRISON
Key concerns
Lincoln (2022)
HMP/YOI Lincoln is regarded as a well-managed Category B local prison, successfully maintaining a humane regime and significantly reducing violence and self-harm despite operational challenges from its Victorian buildings and the pandemic. The Board noted positive developments in healthcare and staff-prisoner relations, alongside efforts to improve the estate. However, significant concerns persist regarding slow progress on repairs, the high incidence of homelessness among discharged prisoners, and the lack of specialist mental health services for personality disorders.
PRISON
Key concerns
IMB individual recommendations(75)— showing 50 strongest matches
London STHF (2024)
In past reports we have recommended that DCOs should be reminded to engage regularly with people during their long periods of detention because people do not remember everything they have been told during their induction. This year again, we observed people who would have benefited from a reminder of what is available to them in the holding rooms.
Other
Bronzefield (2024)
What plans does the prison have to prioritise prisoner/key worker meetings for those prisoners who have been identified as most likely to benefit from them? (5.3)
Governor / Director
Whitemoor (2021)
Will the prison service please review urgently the use of specialised units in order to ensure that better and speedier arrangements can be made for prisoners whose needs are difficult or impossible to meet in a prison like Whitemoor? This would avoid the sad spectacle of men languishing for months at a time in demoralising and degrading conditions.
HMPPS
Noted
Stafford (2021)
Given the many negative comments of the Residents’ Survey regarding staff/resident relationships will the Governor put in place an action plan that is aimed at rectifying these issues?
Governor / Director
Liverpool (2021)
The role of the key worker should be developed, particularly in supporting prisoners who find it difficult to access prison systems.
Governor / Director
In Progress
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That a compass to ascertain the direction of Mecca be available in all HRs and the STHF (see concern (k), above), together with a jug for water ablutions. However, a sign on the wall pointing to Mecca would remove the need for compasses
Home Office
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That a translation device, such as Babel, giving information in a variety of different languages for the hard of hearing, or some other text relay service, be provided for all HRs and the STHF.
Home Office
Peterborough (Women) (2022)
The Board would like to see the restitution of a robust key work system whereby women are aware of this support and know their assigned key worker.
Governor / Director
Norwich (2022)
The Board asks the Governor to provide information on plans for maintaining the focus on decency and provision of basic essentials.
Governor / Director
Norwich (2022)
As the outside community learns to live with Covid, can HMPPS please outline what steps will be taken to return the prison to a more normal regime which would enable rehabilitation and more humane conditions?
HMPPS
In Progress
Garth (2022)
Throughout this year the key worker scheme has not worked effectively because of staff shortages and consequent cross deployment. This should resume as quickly as possible.
Governor / Director
In Progress
Foston Hall (2022)
The suspension of consistent and regular planned contacts by key workers, in line with offender management in custody requirements, thereby reducing rehabilitative and support work with prisoners (see paragraph 5.3.4)
Governor / Director
Stoke Heath (2023)
Can the key worker role to support offender managers in their work for all prisoners be made a priority in the future?
Governor / Director
Preston (2023)
The key worker programme should be increased so as to operate at its designed level.
Governor / Director
Humber (2023)
The Board, in particular, hopes that the key worker scheme will return to the quality and effectiveness we identified prior to the Covid pandemic. The Board acknowledges the difficulties caused by the regular turnover of prisoners but firmly believes an effective key worker programme is vital for a safe and effective establishment.
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2024)
We recommend that these interviews be conducted in a confidential space with more time and care taken to build trust and thereby encourage full disclosure.
Other
North East Midlands, Yorkshire & Humber STHF (2024)
We repeat the recommendation that all arrival interviews should be conducted in the purpose-built interview room in the facility, with privacy and with participants seated in comfort and speaking at eye level. For the reasons outlined in the evidence section (see section 4.1.1) we do not regard the ‘partial acceptance’ of this recommendation last year – namely by offering a …
Other
Haverigg (2024)
Concerns persist around prisoners’ unwillingness, or reported reluctance, to reach out for support when needed. The Board is encouraged by local steps taken to help address this issue and to reassure prisoners, but we recommend that a strong focus is maintained in this key area.
Governor / Director
Noted
Bullingdon (2024)
What steps will the Governor take to address the significant decrease in key working?
Governor / Director
Wayland (2025)
The Board would like to suggest that Practice Plus seriously consider running a survey of their own amongst prisoners to test for themselves the themes we have bulleted above, and also, as a response to the themes we have identified, to consider providing a clear confirmation of the diagnosis made and treatment to be provided after a consultation so the …
NHS / Healthcare Provider
Norwich (2025)
There are currently no ‘baby bonding’ sessions (aimed at introducing prisoners to newborn babies) for prisoners on the category B site, following the removal of facilities in 2023. When will these important sessions be reinstated?
Governor / Director
Cardiff IMB (2025)
Sut mae'r carchar yn bwriadu gwneud ymweliadau'n fwy cynhwysol i garcharorion ac ymwelwyr niwrowahanol?
Governor / Director
Woodhill (2020)
To continue efforts already being made through the Woodhill Growth Project to create a culture where the wellbeing and progression of prisoners is the prime consideration for staff.
Governor / Director
Noted
Yarl’s Wood (2021)
The Board continues to observe that many detained persons, particularly those detained under RSTHF rules, do not fully understand where they are or what will happen to them and at times have become frustrated about the length of their detention. The Board acknowledges that the large numbers of cross-Channel migrants have presented the centre with many challenges that have been …
Governor / Director
Yarl’s Wood (2021)
Vulnerable adults continue to be detained. The pilot scheme Community Action Pilot, Action Access exploring alternatives to detention has produced positive results. The Board recommends that the measures undertaken which improved the health and wellbeing outcomes for vulnerable persons are incorporated into case worker detention evaluation and centre operational procedure instructions for these persons.
Home Office
Thorn Cross (2021)
Thorn Cross is now taking prisoners who are serving longer sentences and who have longer to go to their possible release date. It is now possible for a prisoner to move from a high security prison straight to the open estate. In our view this is unfair on such prisoners who struggle to adapt and need a great deal of …
HMPPS
In Progress
Thameside (2021)
The Board would like to see the same concentrated focus on improving the quality of the daily lives of prisoners where these can be influenced by the actions of staff, especially in the residential areas. IMB members regularly observe how poor communication between managers can stifle improved outcomes for prisoners, and how lack of empathy or thought can rob them …
Governor / Director
Swaleside (2021)
The inequality of opportunity for MCOSO and vulnerable residents still needs to be addressed, despite progress made in that direction. (see sections 5, 5.4 and 5.5)
HMPPS
In Progress
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2021)
That a calendar of notable religious festivals be placed, and be maintained, in each HR and the STHF, and shared with all relevant parties including UKBF officers and C&C DCOs.
Home Office
Gartree (2021)
Can the Governor confirm that there is a simple and clear system in place to ensure that prisoners are able to understand exactly what property they can have in possession and in storage and what additional items they are allowed to order (from approved suppliers) and/or have sent in, and that staff are fully trained to support them with this …
Governor / Director
Gartree (2021)
Will the Governor ensure that all new arrivals are provided with a cell which contains all basic items of furniture and that they are given the clothing and any items they need on arrival at Gartree?
Governor / Director
Cookham Wood (2021)
What will be done to improve the opportunities for boys of all faiths to attend collective/collegiate worship?
Governor / Director
Implemented
Wayland (2022)
The Board recommends to the Governor that greater training effort is made to upskill staff who are in daily contact with prisoners so that they are competent and confident to respond to prisoners who are seeking their help and, also, to proactively interact with prisoners to create the atmosphere and relationships where such interactions can take place.
Governor / Director
Rye Hill (2022)
The difficulties surrounding appropriate arrangements for end-of-life care and compassionate release, imposed by current HMPPS facilities and procedures, impact HMP Rye Hill disproportionately because of the higher than average age profile of the prisoners held. The current procedures do not seem to facilitate humane treatment of these prisoners.
HMPPS
In Progress
Swaleside (2023)
The Board remains concerned about the impact of the recently introduced Offender Flow and Allocation system. Swaleside is a category B trainer in the LTHSE but is now receiving younger prisoners with shorter sentences. This is detrimental to the stability of the prison and the well-being of older, longer sentenced prisoners. The change should be re-examined and the benefit examined …
HMPPS
Moorland (2023)
Can there be a review of how the incentives system might be adapted so that prisoners perceive it as less punitive and more motivating?
Governor / Director
Lewes (2023)
Will the Governor work towards a restoration of the key work scheme to at least pre Covid-19 standards?
Governor / Director
Bristol (2024)
Key working is focused on the high-risk cohorts of prisoners. Will key working be available for all prisoners in the coming year?
Governor / Director
Wealstun (2025)
How will the Governor ensure that key workers sessions are provided for each prisoner and raise their profile?
Governor / Director
Lancaster Farms (2025)
When will the Governor increase the effective use of key working at the prison, with demonstrable targets and outcomes?
Governor / Director
Coldingley (2025)
What is being done to replace the Sycamore Tree restorative justice programme?
HMPPS
Rejected
Bedford (2025)
Will the Governor confirm that this [review rules in respect of clothing for visitors and the amount of money that can be brought in] will happen?
Governor / Director
In Progress
Bedford (2025)
Can the Governor confirm that this [induction supported by a simple leaflet with key messages] will be delivered?
Governor / Director
Bedford (2025)
Will HMPPS confirm that this [consistent approach across all prisons in respect of clothing guidance for visitors and in respect of the amount of money that visitors can spend during visits] will be reviewed?
HMPPS
In Progress
Bedford (2025)
Can HMPPS confirm when Launchpad will be introduced?
HMPPS
In Progress
Bronzefield (2025)
How the prison plans to prioritise prisoner and key worker meetings for those who have been identified as most likely to benefit from them (5.3)?
Governor / Director
Berwyn (2025)
We are still receiving reports from prisoners saying that they do not know who their key worker is.
Governor / Director
Lancaster Farms (2022)
To ensure that contact between prisoners and their key workers becomes more effective.
Governor / Director
Noted
Norwich (2020)
Securing the ethos of enabling environments
Governor / Director
In Progress
Norwich (2020)
maintaining the focus on decency, and particularly the ‘basics’
Governor / Director
Health investigations(533)
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 12
The Trust should develop a system to provide the clinical team with access to any required cultural information and external support agencies. The Trust should: develop community outreach and inreach initiatives with the local community in order to establish culturally appropriate liaison; ensure appropriate links are made with different faith …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 11
The Trust should provide training to highlight the importance, during assessment, diagnosis and treatment, of the patient‟s cultural background. This to include the requirement for: a secondary literature review to be conducted if required; specialist referral if required.
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 10
The Trust will ensure through the audit process that: all care plans are developed, where possible with service users; all care and service delivery is provided in manner sensitive to the needs and wishes of the service users; all care plans are signed, where possible, by service users; all service …
north_west
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (v)
The Trust should encourage a greater input by carers into the information on the basis of which the Care Plan is prepared.
london
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 7
South West Yorkshire Partnership NHS Foundation Trust should take action to ensure that the Spiritual and Pastoral Care Team, or another suitable resource, is available to raise awareness of cultural and religious issues within the clinical arena and that clinical staff have timely access to appropriate advice, consultation and supervision …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 6
South West Yorkshire Partnership NHS Foundation Trust should ensure that the aims of its Equality and Diversity policy are translated into practice in the clinical arena by: ensuring that cultural and religious issues are included in the assessment of need in a routine manner; ensuring that staff receive appropriate training …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 2
Having revised its risk assessment, mangement and training policy the Trust should institute a regular quality audit to ensure: that the formulation of the individual’s problems and needs informs the understanding of his/her risk; that robust and meaningful care plans are put in place; that the service user and other …
north_east_yorkshire
An independent investigation into the care and treatment of a … — Rec Recommendation 2
NHS England (South) should ensure that all mental health provider organisations in its geographical area have a policy in place for the active involvement of carers in the care and treatment of service users. This policy should include clear guidance on how to support carers to remain involved throughout the …
south_east
An independent investigation into the care and treatment of a … — Rec R5
To ensure that all carers are actively involved in Early Intervention in Psychosis throughout the three years the service user is cared for by the service.
south_east
Independent investigation report into the care and treatment of Yusuf — Rec 1
Difficult conversations took place between relatives and hospital staff as Yusuf’s family attempted to access urgent care. • All clinical teams are to be encouraged to attend simulation communication training on conflict in patient care. • It is advised that a reminder be given to staff about responding to parent …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 1
Protocols were appropriately considered in transporting Yusuf to Rotherham Hospital, but there were difficult conversations between Yorkshire Ambulance Service staff and the distressed parents as they sought help from the paramedics for their son who was unwell. This added a slight delay to the transfer. • All clinical teams are …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 1
Yusuf’s mother was expecting to see a GP and not a primary care nurse practitioner when she made an appointment for Yusuf. Patients who make appointments with their GP surgery should be told which healthcare professional they (or their family member) will be seeing, including their name and position.
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 1
At times there was conflict between relatives, paramedic teams and hospital staff while Yusuf’s family attempted to access urgent care. National research should be commissioned to look into why and when parents raise concerns about their children’s acute presentation to health services. There is a need for the development of …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 6
The Specialist Drug and Alcohol Service has put in place a number of initiatives to improve the likelihood that carers and significant others are involved in the assessment of the service user’s needs and the planning of his/her care. The Trust should put in place clear deadlines and reporting and …
south_west
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.10
The interests of the service user should be placed at the centre of the decision to transfer care co-ordination, and not the interests of the relevant service. Transfer of care co-ordination should be agreed with the service user, and this should also be documented.
east_of_england
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.4
The EIP Service should take steps to ensure that, when a clinician wishes to prescribe a drug which is unlicensed for the condition for which it is prescribed, the service user’s express consent is obtained concerning the increased risk of side effects. The EIP Service should review and strengthen its …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
A more direct, proactive and individual approach to the members of victims' families should be adopted by all agencies engaged in crisis support work following homicides and similar events.
east_of_england
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 3
Engagement with patients ought to be achieved by acknowledging their expressed needs and developing an agreed care plan based on those needs.
north_east_yorkshire
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 6
Where serious risks are identified as a result of non-engagement, staff should probe the reasons and not accept the rationalisations the service user presents. To help understand the issues more assertive and focused questioning is required and a pragmatic approach to optimise contact should be taken. The rationale for the …
south_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.k
The Trust and social services authority should give active consideration to the provision of an independent mental health advocacy scheme to assist patients and their carers make comments about the service they receive, and to articulate their own needs and preferences.
north_west
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec h.
That Islamic patients are treated in accordance with the Islamic Code of Medical Ethics.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec f.
That the local PCTs, the Health Authority, the local mental health trust and Birmingham City Council agree an action plan for the delivery of primary and secondary mental health care to South Asian communities that is based not on the notion of ‗an average citizen‘ but on the diversity of …
midlands
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 25
DPT will review its practice standards to ensure that they are more explicit in describing how the views of a person’s family or supporters should inform assessment, formulation and recovery plans.
south_west
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 2
The panel recommends to the Trust that within three months they initiate a plan for implementation of Protected Engagement Time for each clinical area and allocate a specific amount of time to staff so that they have protected time away from administrative duties to spend with patients. (Paragraph 5.1)
east_of_england
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.16
Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that the needs of children and young people with Asperger’s Syndrome, and those with a co-occurring mental health issue, are met comprehensively98.
wales
Independent investigation: Gwen Poole, Llanbradach, Caerphilly (2009) — Rec 3.15
Aneurin Bevan Health Board and Caerphilly County Borough Council must ensure that services’ eligibility criteria do not exclude patients with complex needs. Eligibility criteria must be flexible, with the core emphasis focused on individuals’ needs.
wales
Independent investigation into the care and treatment of Mr X … — Rec 10
To develop workshops involving themes of the stigma of mental illness and associated features of masking and denial of symptoms, in the context of comparison of various cultural norms as well as an appreciation of the service user as an individual who may or may not share various cultural/ social …
london
Independent investigation: Faith Lovemore (6 wks), Cambridge (2009) — Rec 4
Families or individuals must not be deprived of appropriate clinical services because their beliefs make them difficult to engage. The following must be considered: • the Trust is responsible for ensuring appropriate provision is made to engage those who are reluctant, for whatever reason, to become involved with clinical services; …
east_of_england
Independent investigation into the care and treatment of Mr X — Rec 12
The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular. Guidelines should be developed in relation to the culture and identity of Somali people with reference also made to the additional impact of asylum seeker and …
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation into the care and treatment of Mr X — Rec 2
Guidelines should be developed to assist in the development of diagnostic formulations for Somali service users. The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular.
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation: Carla Thompson, Merton (1998) — Rec 3
The Inquiry Panel recommends that all NHS Trusts providing mental health services should ensure that their local operational policies explicitly address the needs of deaf people with mental health problems, and that these policies are consistent with national guidance.
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 19
East London and The City Mental Health NHS Trust should review its policy on spiritual care so as to recognise the possible risks, as well as benefits, of the involvement of religious or spiritual advisors in supporting a person with a mental illness; every effort should be made to engage …
london
Independent investigation: Asiya Khatun, Newham (2000) — Rec 6
East London and The City Mental Health NHS Trust and the London Borough of Newham should ensure their compliance at the earliest date with the involvement of carers in CPA assessment, care and treatment plans, in accordance with Standard 6 of the National Service Framework for Mental Health.
london
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R12
We recommend to PCTs, Trusts and Social Services that it should be re-emphasised to those involved in making recommendations for placements for psychiatric patients that the primary concern must always be the patient’s individual needs, rather than financial considerations.
south_east
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 25
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a regular review of their care plan, and that the review involves the patient and their carers.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 24
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a crisis plan, and that the crisis plan is agreed with the patient and their carers.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 23
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a written care plan, and that the care plan is agreed with the patient and their carers.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 6
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people from black and minority ethnic communities, including culturally appropriate services and advocacy services.
midlands
Independent investigation: Vincent Francis, Wells (2009) — Rec 7
Clear statements should be made on the philosophy and values of the contributing specialist services and agencies. These should describe professional interventions which satisfy service users, families and carers, and degree of risk. They should promote risk sharing and management, inclusiveness e.g. those with personality disorders and young people who …
south_west
Independent investigation: Vera Croghan, Norwich (2020) — Rec 4
Development and roll-out of DIALOG and DIALOG + must be maintained and reviewed and audited to ensure that social, cultural, familial, and other patient-based information can be built into care more effectively.
east_of_england
Independent investigation: Vera Croghan, Norwich (2020) — Rec 3
The Trust will strengthen arrangements for assessments of safeguarding and teams (in team meetings and in supervision) should strengthen the way that they engage with families to maintain their professional curiosity about the wider impact in families. The clinical team should reinforce their policy for `Think Family14.
east_of_england
Independent investigation: Valerie Thomas, Cardiff (2005) — Rec 5
Cardiff and Vale NHS Trust and Cardiff County Council should: (a) develop structures, systems and procedures which will require, encourage and support active engagement of those health and social care services with patients/clients who may have difficulties in complying with rigid, formal arrangements for contact, including people who are homeless, …
wales
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020) — Rec 6
EPUT should ensure that communication with mental health patients about prospective or missed appointments takes into account the potential that the patient may be vulnerable due to mental disorder and may have difficulty in engaging and forming relationships with service providers and as a result may need more assistance/support to …
east_of_england
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020) — Rec 4
EPUT should embed a process to ensure that when a referral is accepted to their community mental health teams the care coordinator or other relevant professional working with that patient makes contact with the patient’s family/carers at the earliest opportunity to provide a point of contact for the family and …
east_of_england
Independent investigation: Tom Easton, Old St, London (2006) — Rec 7
Any systems of care and treatment for service users with severe and enduring mental ill health should be as simple as possible and encourage the individual to engage and cooperate with mental health services and not place unnecessary and cumbersome barriers in their path. The processes in place within the …
london
Independent investigation: Stuart Hopkin, Shepton Mallet (2020) — Rec 1
Family engagement. Families supporting an individual must be involved in HTT mental health assessments. In instances where a family member is not involved, the assessing staff should document the rationale.
south_west
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station … — Rec 1
The Cultural Competencies Toolkit needs a separate section to address the cultural issues that are clearly significant to experiences in South Asian culture. Reference needs to be made to honour codes and ‘izzat’ both of which are fundamental to the experiences of South Asian communities. In highlighting these experiences examples …
london
Independent investigation: Sharon Stokes, Exmouth (2007) — Rec 3.7.2.1.
The Devon Partnership NHS Trust should draw up guidelines, in line with best practice, on case formulation. Amongst other things this should cover the importance of trait-like characteristic as well as more transient symptomatology, the involvement of the patient and his/her family/carers, and the regular reviewing of the formulation. In …
south_west
Independent investigation: Sharon Stokes, Exmouth (2007) — Rec 3.7.1.1.
The Devon Partnership NHS Trust should undertake a review of its policies and practices to ensure that families and carers, where appropriate, are involved in assessment and care planning. The current CPA 2 Assessment should be revised to identify the expectation that families and carers are involved in assessment and …
south_west
Independent investigation: Sean Hand, Basildon (2003) — Rec 105.5
That the Trust be requested to confirm that Consultant Psychiatrists and Care Co-ordinators are aware of their obligations to close relatives of clients to ensure that such relatives clearly understand the nature and effect of the client's mental illness.
east_of_england
Scottish Fatal Accident Inquiries(4)
Lin Jin Wu
I recommend that the prison look at introducing for issue to prisoners a more formalised set of cards, in various languages, with the sort of words and phrases which Mr Mckinney found helpful in Wu's case. I recommend that the Scottish Prison Service do not delay in completing an assessment of the viability of introducing Language Line. A helpful suggestion …
Aug 2004
Tran Quang Tung
Having regard to the evidence led at this Inquiry it is recommended that: Persons who are detained by the authorities and who do not speak or have a good understanding of English should have access to an interpreter on any occasion on which (a) they are being interviewed in a context in which either their right to remain in the …
Sep 2005
Sophie Anne Parkinson
(i) I recommend CAMHS provide written information to CAMHS patients and their carers explaining the organisational structure and role of clinicians within CAMHS; (ii) I recommend that CAMHS investigate the viability of “safe space” beds as currently provided to CAMHS patients of the Lancashire and South Cumbria NHS Foundation Trust; (iii) I recommend that CAMHS provide an out of hours …
Sep 2020
Health
3 recs
James Hutchison
(5) Recommendations I make the following recommendations (where I refer to a nursing home it should be understood that I am referring to a nursing home for elderly and mentally infirm persons, an EMI home) :- (a) When any elderly and mentally infirm person (probably therefore a person suffering from dementia) is to be admitted to a nursing home there …
Dec 2006
Article 2 learning points(3)
— LP 5
I recommend that the Governor of HMP Ranby is asked: to note the absence of case notes or other evidence of constructive engagement with WA; to consider what practical arrangements are now in place at Ranby to cultivate positive interaction between staff and prisoners and whether more can be done; …
The Governor (HMP Ranby)
— LP 17
To make better use of pre‐existing information, we recommend that psychiatric assessment guidelines used on HMP Pentonville’s Healthcare unit reference the need to source and consider the results of medical and psychiatric assessments that may have been conducted by other institutions.
PPG
Accepted
— LP 12
We recommend that HMP Pentonville’s Healthcare unit reviews its use of ‘Special Observation forms’ and clarifies what value, if any, they are adding to the care and management of a prisoner who is on an observation regime.
PPG
Accepted
Detention investigations(2)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R30
Pregnant residents should be allowed to eat their meals away from the main dining rooms without having to obtain permission from healthcare staff.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R9
Managers undertaking the current staffing review should address the question of how staff can best be given time to engage with residents and meet their emotional as well as practical needs.
Immigration Detention
Independent reviews(50)
Neurodivergence Task and Finish Group: report — Rec 6
Recommendation Six: Adapt learning environments and ensure behaviour policies are rooted in an inclusive school culture that values understanding, acceptance and curiosity Inflexible learning environments, teaching styles, physical spaces, and rigid school policies, often create barriers for neurodivergent children and young people, as well as some of their neurotypical peers …
Health & Social Care
Neurodivergence Task and Finish Group: report — Rec 5
Recommendation Five: Allow more flexible forms of assessment and curriculum It is essential that the curriculum and assessment system goes further in offering flexibility to neurodivergent children and young people where necessary. Not just in what is taught, but in how it is delivered [19, 22]. Topics should reflect children …
Health & Social Care
Neurodivergence Task and Finish Group: report — Rec 2
Recommendation Two: Introduce a ‘commitment to listen’ to parents/carers and neurodivergent young people and recognise where schools do this well Whilst schools and teachers are responsible for and have expertise in educational needs and support strategies, parents/carers should be valued partners in the education of their children [6]. Parents are …
Health & Social Care
Litchfield WCA Review Year 5 — Rec 7
Further work to develop and implement a semi-structured interview should continue. This should be developed in conjunction with a small number of representative groups. Particular attention should be paid to interview practices for those with mental health conditions, learning disabilities and autism, and this should be reflected in the guidance …
Employment & Work
Litchfield WCA Review Year 4 — Rec 32
Consideration is given to a new reassessment period extending to 5 years in the Support Group for people who have very severe incapacity resulting from brain disorders that are degenerative or which will not realistically improve.
Employment & Work
Litchfield WCA Review Year 4 — Rec 8
The Department should specify an assessment format that facilitates better rapport, such as the HCP and person being assessed sitting side by side.
Employment & Work
Keogh Cosmetic Interventions Review — Rec 32
Providers and practitioners should provide continuity of care. Patients should be offered appropriate follow-up and after-care, rather than stand-alone procedures.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 27
The RCS Interspecialty Committee on Cosmetic Surgery should develop and describe a multi-stage consent process for operations. This consent process should be undertaken by the operating surgeon and its use should be mandated as part of the Code of Practice.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 26
Patient Decision Aids (PDAs) should be developed for cosmetic procedures and these should be piloted by the RCS Interspecialty Committee on Cosmetic Surgery.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 25
Evidence-based standardised patient information should be developed by the RCS Interspecialty Committee on Cosmetic Surgery. This should be done with input from patient organisations. This information should be available on NHS Choices and the Parliamentary Health Service Ombudsman (PHSO) website.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 24
Healthcare providers must actively promote and support patient and public involvement in nursing education through their patient experience strategies, education strategies and board-level quality assurance processes.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 23
Local education and training boards (and their equivalents), healthcare providers and universities should jointly deliver a comprehensive, strategic and transparent approach to patient and public involvement in pre-registration nursing education. It should encompass training and rewards for service users and carers, and development for academic and clinical staff so they …
Health & Social Care
Willis Commission on Nursing 2012 — Rec 22
The NMC standards on patient and public involvement in pre-registration nursing education must be fully implemented, as a vital step in putting the experiences of patients and the public at the heart of nursing education.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 12
The quality of many practice learning experiences urgently needs improvement. Learning to care in real-life settings lies at the heart of patient-centred education and learning to be a nurse.
Health & Social Care
Mental Health Taskforce 2016 — Rec 51
The Department of Health should work with a wide range of stakeholders to review whether the Mental Health Act (and relevant Code of Practice) in its current form should be revised in parts, to ensure stronger protection of people’s autonomy, and greater scrutiny and protection where the views of a …
Health & Social Care
Mental Health Taskforce 2016 — Rec 47
NHS England and NHS Improvement should together lead on costing, developing and introducing a revised payment system by 2017/18 to drive the whole system to improve outcomes that are of value to people with mental health problems and encourage local health economies to take action in line with the aims …
Health & Social Care
Mental Health Taskforce 2016 — Rec 38
By April 2017, HEE should work with the Academy of Medical Royal Colleges to develop standards for all prescribing health professionals that include discussion of the risks and benefits of medication, and take into account people’s personal preferences, including preventative physical health support and the provision of accessible information to …
Health & Social Care
Mental Health Taskforce 2016 — Rec 30
NHS England and NHS Improvement should encourage providers to ensure that ‘navigators’ are available to people who need specialist care from diagnosis onwards to guide them through options for their care and ensure they receive appropriate support. They should work with HEE to develop and evaluate this model.
Health & Social Care
Mental Health Taskforce 2016 — Rec 25
The MCP, PACS, UEC Vanguards and the Integrated Personalised Commissioning programme should be supported to ensure that the inclusion of payment for routine integrated care adequately reflects the mental health needs of people with long-term physical health conditions. Vanguard sites should also provide greater access to personal budgets for people …
Health & Social Care
Harris Review: Deaths in Custody — Rec 62
The ICP should be developed by the CARO, in consultation with the young adult concerned in order to identify how, by whom and when their needs identified by the SAVRAS process, will be met.
Justice & Legal
Bubb Report — Rec 8
The commissioning framework should be accompanied by a closure programme of inappropriate institutional inpatient facilities. This active decommissioning should be driven by a tougher approach from the Care Quality Commission, local closure plans, and closures led by NHS England where it is the main commissioner. NHS England should come to …
Health & Social Care
Bubb Report — Rec 7
Community-based providers should be given a 'right to propose alternatives' to inpatient care to individuals, their families, commissioners and responsible clinicians.
Health & Social Care
Bubb Report — Rec 4
NHS England should extend the right to have a personal budget (or personal health budget) to more people with learning disabilities and/or autism, including all those in inpatient care and appropriate groups living in the community but at risk of being admitted to inpatient care.
Health & Social Care
Bubb Report — Rec 3
People with learning disabilities and/or autism and their families should be given a 'right to challenge' decisions to admit or continue keeping them in inpatient care. They should receive independent expert support to exercise that right, including high-quality independent advocacy.
Health & Social Care
Bubb Report — Rec 1
The Government should draw up a Charter of Rights for people with learning disabilities and/or autism and their families, and it should underpin all commissioning. The Charter should clarify existing rights, and set out new rights we propose below. The mandatory commissioning framework later in our recommendations should require all …
Health & Social Care
Francis Inquiry (Mid Staffs 2010) — Rec 1
The Trust must make its visible first priority the delivery of a high-class standard of care to all its patients by putting their needs first. It should not provide a service in areas where it cannot achieve such a standard.
Health & Social Care
Laming Review (Baby P) — Rec 19
The Department for Children, Schools and Families must strengthen Working Together to Safeguard Children, and Children's Trusts must take appropriate action to ensure: all referrals to children's services from other professionals lead to an initial assessment, including direct involvement with the child or young person and their family, and the …
Other
Laming Review (Baby P) — Rec 13
Children's Trusts must ensure that all assessments of need for children and their families include evidence from all the professionals involved in their lives, take account of case histories and significant events (including previous assessments) and above all must include direct contact with the child.
Other
Paterson Inquiry — Rec 4
We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. We recommend that the GMC monitors this as part of 'Good Medical Practice'.
Health & Social Care
Paterson Inquiry — Rec 3
We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised, is explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by …
Health & Social Care
Paterson Inquiry — Rec 2
We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than writing to the GP and sending a copy to the …
Health & Social Care
Berwick Review — Rec 3
Patients and their carers should be present, powerful and involved at all levels of healthcare organisations from wards to the boards of Trusts.
Health & Social Care
Corston Report — Rec 30
Services should be provided based on the one-stop-shop approach of centres like Asha and Calderdale and must be appropriate and coordinated to meet the profiled needs of local women, including minorities such as BME women.
Justice & Legal
Shaw Detention Review — Rec 59
Recommendation 59: I recommend that all caseworkers should meet detainees on whom they are taking decisions or writing monthly detention reviews at least once. The meeting should be face-to-face, or by video link, or by telephone.
Immigration
Selous Review — Rec 100
The Ministry of Defence and the Armed Forces to review legislative requirements and remove the use of terminology which is regarded as being out-of-date, demeaning and disempowering, particularly references to non-serving partners/spouses as ‘dependents’, in all policies and procedures which relate to everyday military family life.
Other
Coates Prison Education Review — Rec 2
Every prisoner must have a Personal Learning Plan that specifies the educational activity that should be undertaken during their sentence. This should be in a consistent digital format that can follow the prisoner through the system if they move prisons. This plan should be informed by initial assessment, be subject …
Justice & Legal
East Kent Maternity Review — Rec 2
• Those responsible for undergraduate, postgraduate and continuing clinical education be commissioned to report on how compassionate care can best be embedded into practice and sustained through lifelong learning. • Relevant bodies, including Royal Colleges, professional regulators and employers, be commissioned to report on how the oversight and direction of …
Health & Social Care
Wade-Gery Review — Rec 1
Recommendation 1: commit to a patient and citizen centred organising principle for future service transformation The NHS must be bolder in stating that the health and care system should empower citizens to manage their health and well-being and give them the tools to take ownership. The citizen should expect services …
Health & Social Care
MacAlister Review — Rec 39
Independent, opt-out, high quality advocacy for children in care and in proceedings should replace the existing Independent Reviewing Officer and Regulation 44 Visitor roles. The Children’s Commissioner for England should oversee these advocacy services, with the powers to refer children’s complaints and concerns to the court.
Education
MacAlister Review — Rec 37
Foster carers should be given delegated authority by default, to take decisions which affect the day to day lives of children in their care.
Education
MacAlister Review — Rec 36
Local authorities, and eventually Regional Care Cooperatives, should use family group decision making to identify important adults that are already known to a child and may be willing to foster.
Education
MacAlister Review — Rec 30
Contact arrangements between birth parents, adopted children and adoptive parents should be assumed by default and modernised through the swift roll out of technology enabled methods of contact, such as Letterswap.
Education
MacAlister Review — Rec 23
Government should introduce legislation which makes the use of family group decision making mandatory before a family reaches Public Law Outline. The features and delivery practice of effective family group decision making should also be included in the National Children’s Social Care Framework.
Education
MacAlister Review — Rec 22
The Public Law Working Group should lead work to bring learning from the Family Drug and Alcohol Courts and other problem solving approaches into public law proceedings, to make proceedings less adversarial and improve parents’ engagement in the process.
Education
MacAlister Review — Rec 20
The National Children’s Social Care Framework practice guides should promote effective practice for engaging families. Parental representation should be offered to all families in child protection.
Education
MacAlister Review — Rec 4
Family Help should be delivered by multidisciplinary teams, embedded in neighbourhoods, harnessing the power of community assets and tailored to local needs.
Education
MacAlister Review — Rec 3
Local Family Help Teams should be designed in a way that enables families and practitioners to have a conversation about their concerns rather than relying on mechanical referrals. If families are not eligible for Family Help, support should be available in universal and community services and the front door to …
Education
MacAlister Review — Rec 2
Eligibility for Family Help should be set out in a sufficient level of detail nationally to give a more consistent understanding of who should receive Family Help, whilst giving enough flexibility to enable professional judgement and empower Family Help Teams to respond flexibly to families' needs.
Education
Wessely Review — Rec 116
Government should consider making it a requirement that the parents and families of young people placed out of area are supported to maintain contact.
Health & Social Care
Accepted
Wessely Review — Rec 113
Every inpatient child or young person should have a personalised care and treatment plan which records the views and wishes of the child or young person on each issue. Government should consider whether there should be a statutory duty for such a plan where the child or young person does …
Health & Social Care
Accepted
PHSO casework decisions(215)
P-001097 — University Hospitals Sussex NHS Foundation Trust
Mrs U complained she did not receive planned sedation for a procedure and was not offered the option to reschedule, causing severe pain and distress.
NHS in England
Partly Upheld
Aug 2021
P-001233 — Buckinghamshire Healthcare NHS Trust
Ms T complained the Trust provided inadequate care for her partner Mr S, including poor hydration, hygiene, and compassion, and failed to communicate his deteriorating health and death.
NHS in England
Upheld
Dec 2021
P-001329 — The Dudley Group NHS Foundation Trust
Mrs O complained about her late husband's rapid deterioration in hospital, alleging incorrect Parkinson's medication, inadequate nutrition/fluid monitoring, and inappropriate use of continence pads.
NHS in England
Mar 2022
P-003898 — Guy’s and St Thomas’ NHS Foundation Trust
Mrs P complains about a traumatic endoscopy procedure on 11 July 2020, alleging it was done without anaesthesia, without lubricant, and continued despite her signalling to stop, causing severe pain and injury.
NHS in England
Sep 2023
P-002650 — Northern Lincolnshire and Goole NHS Foundation Trust
Mr and Miss U complained their father's DNACPR decision was against his wishes and religious beliefs. They also alleged staff provided inadequate information and were rude and unprofessional.
NHS in England
May 2024
P-002752 — A practice in the City of Derby area
Mrs R alleged the midwife failed to signpost housing support, and the Trust did not help with a birth plan, communicate during labour, get consent, or address her anxiety after a traumatic birth.
NHS in England
Partly Upheld
Jul 2024
P-003285 — Warrington and Halton Hospitals NHS Foundation Trust
Miss E complained staff performed foetal scalp monitoring, additional blood samples, and an episiotomy during her labour without her consent, causing lasting psychological and physical trauma.
NHS in England
Upheld
Jul 2024
P-002926 — University Hospitals Birmingham NHS Foundation Trust
Miss I complained her father's condition deteriorated from able-bodied to disabled, leading to his death, and that the family was pressured into a DNR order and denied visits.
NHS in England
Sep 2024
P-003124 — Mid Yorkshire Teaching NHS Trust
The nursing team did not follow care plans for her mother’s leg blisters and refused to let Mrs N stay with her mother during end-of-life care, causing pain and distress.
NHS in England
Upheld
Nov 2024
P-003297 — Royal Devon University Healthcare NHS Foundation Trust
Mrs E complained Royal Devon University Healthcare NHS Foundation Trust staff failed to communicate with her and her son, inappropriately discharged him without monitoring, and stopped his omeprazole prescription.
NHS in England
Partly Upheld
Jan 2025
P-003295 — South Tyneside and Sunderland NHS Foundation Trust
Miss U complained the Trust failed to provide her mother adequate hydration and did not communicate its decision to place a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) order.
NHS in England
Upheld
Jan 2025
P-003798 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complained staff did not listen to her father's unwellness and the Trust failed to provide regular BSL interpreters, instead using her children. She also questioned the complaint meeting interpreter and response.
NHS in England
Partly Upheld
Mar 2025
P-003480 — A dental practice in the Torbay area
Mr P complained the dentist removed all his teeth against his will without discussing other options, causing pain with dentures, affecting eating, smiling, and mental health.
NHS in England
Apr 2025
P-003942 — Oxford University Hospitals NHS Foundation Trust
Ms T complained the Trust only offered hormone therapy for Mr R's prostate cancer, informed him of brain cancer against his wishes, and provided inappropriate physiotherapy after hip replacement, which she believed led to his deterioration.
NHS in England
Upheld
Sep 2025
P-004165 — Barking, Havering and Redbridge University Hospitals NHS Trust
His aunt was incorrectly told her cancer had spread and treated as palliative without family consultation, receiving substandard care. He also complained of poor communication and inadequate complaint handling.
NHS in England
Oct 2025
P-004368 — East Suffolk and North Essex NHS Foundation Trust
Mrs R complained the Trust failed to administer her mother's Parkinson's medication, provided inadequate care, ignored advanced wishes, and didn't communicate with her, contributing to an avoidable death.
NHS in England
Nov 2025
P-004377 — Harrogate and District NHS Foundation Trust
Mr Y complained his son was incorrectly discharged without diagnosis or treatment, and the Trust disregarded private medical opinions. This resulted in prolonged pain and further surgery.
NHS in England
Nov 2025
P-004394 — South London and Maudsley NHS Foundation Trust
Ms J complained the Trust did not adhere to her reasonable adjustment requests, inaccurately recorded her clinical history, and poorly handled her complaint.
NHS in England
Dec 2025
P-004400 — Mersey and West Lancashire Teaching Hospitals NHS Trust
A man complained his father experienced frequent ward moves, suffered falls due to inadequate prevention, and the family received poor communication from the Trust.
NHS in England
Dec 2025
P-004784 — A practice in the Oadby and Wigston area
Ms A complained the practice decided her mother should be nil by mouth without a proper assessment, and about the time taken and lack of communication in complaint handling.
NHS in England
Upheld
Feb 2026
P-004765 — A dental practice in the Hounslow area
Miss A complained about pre-crown work done without adequate pain relief and with a poor attitude, resulting in a cut tongue and trauma.
NHS in England
Jan 2026
P-001066 — University Hospitals Sussex NHS Foundation Trust
Mrs E complained the Trust left her for 12 days without treatment for shortness of breath and discharged her too soon. She also alleged her leg wound was left untreated, leading to MRSA.
NHS in England
Upheld
May 2021
P-001165 — Royal United Hospitals Bath NHS Foundation Trust
Mrs G complained the Trust failed to provide an interpreter for her husband, administered transfusions without consent, denied food, made a DNR decision without family input, and incorrectly prescribed medication.
NHS in England
Upheld
Oct 2021
P-001175 — North Middlesex University Hospital NHS Trust
Miss A complained her late father developed bed sores due to poor hospital care, staff failed to communicate with her about them, and he was not given prescribed pain relief.
NHS in England
Upheld
Oct 2021
P-001314 — The Rotherham NHS Foundation Trust
Mrs O complained the Trust moved her husband to palliative care and withheld intubation/ventilation without his consent, denying him a last chance of survival from COVID-19.
NHS in England
Feb 2022
P-001509 — The Royal Wolverhampton NHS Trust
A mother complained a doctor failed to listen to her and physically examine her dehydrated son, delaying a diagnosis of intussusception and worsening his condition.
NHS in England
Aug 2022
P-001832 — Cambridge University Hospitals NHS Foundation Trust
Miss V complained about poor safeguarding, delayed scan sharing, failed medical procedures, communication issues, lack of consent, and unsuitable accommodation during her son's care in April 2018.
NHS in England
Nov 2022
P-001628 — A medical practice on the Isle of Wight
Mrs T complained about unacceptable delays in restarting her vitamin B-12 injections, which caused concentration/fatigue issues, and poor communication about her care with NHS England.
NHS in England
Nov 2022
P-001619 — East and North Hertfordshire NHS Trust
Ms KN complained about poor care for her vulnerable mother in ED, including delayed pain relief, lack of food/drink, no ID bracelet, and poor staff attitude.
NHS in England
Upheld
Nov 2022
P-001717 — Avon and Wiltshire Mental Health Partnership NHS Trust
Mr A complained about poor communication, lack of debriefs, early discharge, and insufficient consideration of his fiancée's autism during her inpatient anorexia treatment.
NHS in England
Partly Upheld
Jan 2023
P-001713 — Liverpool University Hospitals NHS Foundation Trust
Mr U experienced significant delays in being seen at A&E, inappropriate observations, lack of food/drink, and his family was not involved in the DNACPR decision.
NHS in England
Partly Upheld
Jan 2023
P-001820 — A practice in the Derbyshire area
Ms R complained about poor clinical care for her father, including an inadequate telephone assessment, lack of follow-up for serious symptoms, and poor complaint handling.
NHS in England
Feb 2023
P-001826 — A practice in the Calderdale area
Mrs A complained the Practice poorly communicated and repeatedly misdiagnosed her mother over the phone, leading to her death from an undiagnosed infection.
NHS in England
Feb 2023
P-001818 — A practice in the Somerset area
Miss O complained her practice gave mixed messages about asthma, ignored eczema concerns, did not examine a neck lump, and had poor phone and online booking systems.
NHS in England
Feb 2023
P-001876 — A dental practice in the Kingston upon Thames …
Mr R complained his dental practice cemented a crown without his review and that it was too large, causing embarrassment, eating difficulties, and impacting his confidence.
NHS in England
Upheld
Mar 2023
P-001908 — Northern Care Alliance NHS Foundation Trust
Mrs C complained the Trust failed to investigate her sister's symptoms and implement her care plan, delaying cancer diagnosis. She also cited insensitive staff comments.
NHS in England
Mar 2023
P-001900 — The Chaseley Trust
Mrs R complained staff administered too much Fucidin cream, failed to administer eye drops correctly, and did not notify her about a hospital appointment.
NHS in England
Mar 2023
P-001882 — South Warwickshire NHS Foundation Trust
Mrs U complained a DNAR notice was added without her consent, her husband's blood tests and medication were mismanaged, and she was not notified of his death for six hours.
NHS in England
Mar 2023
P-001884 — A hospital in the Sheffield area
Mr I complained the Hospital provided ineffective pain management after his knee replacement operation and handled his subsequent complaint inefficiently.
NHS in England
Mar 2023
P-001863 — Leicestershire Partnership NHS Trust
Ms L complained her mother’s GP failed to visit and delayed end-of-life care and pain relief. She also alleged district nurses improperly gave medication and did not respond to calls.
NHS in England
Mar 2023
P-001894 — Manchester University NHS Foundation Trust
Ms R complained the Trust failed to manage her mother's pain effectively before her death and exhibited poor communication, causing confusion and distress to the family.
NHS in England
Mar 2023
P-001867 — The Princess Alexandra Hospital NHS Trust
Mrs E complained about her son's palliative care, citing conflicting information, unexplained syringe driver use, unmanaged pain, and no doctor review available in his final hours.
NHS in England
Mar 2023
P-001930 — United Lincolnshire Hospitals NHS Trust
Mr L complained the Trust mismanaged his late wife's vulnerability and treatment, failed to communicate with him, restricted visits, and incorrectly recorded her death.
NHS in England
Apr 2023
P-003885 — A practice in the Kent area
Mrs O complained the Practice prescribed end-of-life medication to her husband without discussion, examination, or family consultation, despite him being due for cancer treatment.
NHS in England
Jul 2023
P-003877 — Nottingham University Hospitals NHS Trust
Ms T complained the Trust's care for her mother, Mrs T, failed in individualised care, coordinated planning, and communication, leading to her deterioration and death.
NHS in England
Partly Upheld
Jul 2023
P-003284 — University Hospitals Birmingham NHS Foundation Trust
The Trust allegedly failed to gain consent for and forced catheterisation on E, causing pain. There were also delays in handling Miss O's complaint.
NHS in England
Upheld
Sep 2023
P-003873 — Guy's and St Thomas' NHS Foundation Trust
The Trust allegedly denied Mrs E a reasonable adjustment to stay overnight with her disabled daughter and failed to book onsite accommodation.
NHS in England
Sep 2023
P-003896 — Cambridge University Hospitals NHS Foundation Trust
Mr A complained about an unsuccessful nose operation resulting in persistent bleeding and breathing difficulties. He cited poor service and a rude, uncommunicative consultant.
NHS in England
Sep 2023
P-002288 — Northern Lincolnshire and Goole NHS Foundation Trust
Mrs J complained the Trust wrongly accepted her brother's capacity for a ReSPECT form and then inappropriately used it to withdraw treatment, resulting in an undignified death.
NHS in England
Nov 2023
P-002386 — Lancashire and South Cumbria NHS Foundation Trust
Mr N complained about the Trust's diagnosis and a lack of patient-centred support, which he believes worsened his mental health.
NHS in England
Dec 2023
LGO / SPSO decisions(60)
21-016-787 — Kent County Council
Summary: Mr X complains the Council’s care provider, Expertise Homecare (Ashford), failed to meet his late mother’s needs, putting her at risk of harm. His mother did not always receive person centred care and was put at risk of harm by some of her care workers. This caused avoidable distress …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-004-508 — Kent County Council
Summary: Mr X complains the Council failed to meet his son’s care and support needs when it prevented him from accessing more than one day service because of COVID-19, which had an adverse impact on his well-being. The Council failed to assess all the risks and failed to consider what …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2022
23-015-685 — Milton Keynes Council
Summary: Mr X complains the Council decided without his involvement that it would place his disabled son, P, in residential care. However, that did not happen, and P is now settled in a day service placement of his parents’ choice, funded through the NHS. There is no evidence that P …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-018-947c — Allison House (23 018 947c)
Summary: Ms Y complained that professionals failed to understand her mother’s personality and wrongly determined she lacked capacity. Ms Y said this led to a decision to transfer her mother to a nursing home which caused her distress. In addition, she said it led to a hospital and a nursing …
LGO (Local Government & …
Health
Not Upheld
Jul 2024
23-018-947a — North Tees and Hartlepool NHS Foundation Trust (23 …
Summary: Ms Y complained that professionals failed to understand her mother’s personality and wrongly determined she lacked capacity. Ms Y said this led to a decision to transfer her mother to a nursing home which caused her distress. In addition, she said it led to a hospital and a nursing …
LGO (Local Government & …
Health
Not Upheld
Jul 2024
NIPSO-202001016 — Western Health and Social Care TrustNorthern Ireland Hospice
The daughter of an elderly cancer patient complained that her syringe driver was removed in the days before her death, causing her to experience unnecessary pain.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2024
21-012-160 — Bournemouth, Christchurch and Poole Council
Summary: Mr X complains the Council has failed to make reasonable adjustments when communicating with him, resulting in avoidable distress and unnecessary time and trouble in pursuing his concerns. The Council has accepted its failings and has taken steps to ensure Mr X receives the service he needs in future. …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2022
22-004-316 — South Gloucestershire Council
Summary: We will not investigate this complaint about the Council illegally keeping Mr B from caring for his wife, lying, and disrespecting him. This is because
LGO (Local Government & …
Adult Care Services
Jul 2022
21-011-711d — CSH Surrey (21 011 711d)
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-011-711c — Woking and Sam Beare Hospice and Wellbeing Care …
Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
21-018-113 — London Borough of Hounslow
Summary: Mr X complained the Council failed to ensure his family are suitably housed given Mrs X’s disabilities. The Council was not at fault for the way it dealt with Mr X’s housing priority, housing allocation and care needs assessment. The Council was at fault as it failed to consider …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
22-002-110 — Herefordshire Council
Summary: Miss C complains that the Council said it would move her daughter, Miss D, to a care home closer to the family home when a place became available but refused to do so. The Council was at fault for poor communication with Miss C. This fault caused injustice as …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
22-002-090 — Northumberland County Council
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-006-318 — South Gloucestershire Council
Summary: There were communication failures in respect of Mr X’s needs and a failure to understand new practices which led to a delay in moving him to a nursing home in his home area. There were also failures to communicate properly with Mr X’s wider family. The Council agrees to …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-012-707 — Gloucestershire County Council
Summary: Mrs X complained about contact restrictions between her relative Ms Y and Ms Y’s mother Mrs Z which the Council continued to impose after Ms Y left a care home. The Council was at fault for failing to clarify the nature of the restrictions and the actions needed to …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
23-004-023a — Carpathia Grange (23 004 023a)
Summary: We have found fault with pressure care management and record keeping by a care home. On balance we do not consider this caused harm, but it has led to uncertainty around pressure care and the speed of recovery. The Council and the care home accepted our recommendations, which included …
LGO (Local Government & …
Health
Upheld
Jun 2024
23-013-439 — North Yorkshire Council
Summary: Ms X complained about the handling of her Disabled Facilities Grant (DFG) application. She says the proposed adaptations to her property are not fit for purpose and do not create sufficient space for her family. Mrs X complained the Council did not consider her family holistically or take account …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-010-073 — North East Lincolnshire Council
Summary: Mr X complained Care Plus Group Ltd, acting on behalf of the Council, unsafely discharged his late father Mr Y from residential respite care to his home without proper assessments and care planning. There was fault in the assessment and care planning process, which caused distress to Mr Y …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-023-076 — Brighton & Hove City Council
Summary: Mx X complains for Ms Y the Council was at fault in the way it provided her with care and support. We have found no evidence of fault in the way the Council considered these matters. So have completed our investigation.
LGO (Local Government & …
Adult Care Services
Not Upheld
Dec 2025
PSOW-202105742 — Betsi Cadwaladr University Health Board
Mrs J complained about the actions of the Learning Disability Team (“the LD Team”) of the Health Board in response to her request to provide assistance to move her sister, Miss M, from the upstairs of her home to a new home with Mrs J and her family in April …
PSOW (Public Services Om…
Health
Upheld
Dec 2022
21-010-549 — London Borough of Hammersmith & Fulham
Summary: Miss X complained about the support the Council provided when she was moving home. Miss X also complained the Council refused to carry out a review of her care plan. Miss X says this has affected her mental and physical health. We find fault with the Council for a …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
20-012-439 — Reading Borough Council
Summary: Mr Y complains about the Council’s handling of his reports of noise nuisance from his neighbour. Mr Y says this caused stress and distress, and affected his ability to sleep and work. We do not find fault in the Council’s decision that there was no evidence of a statutory …
LGO (Local Government & …
Environment And Regulation
Upheld
Jun 2022
21-017-741 — Leeds City Council
Summary: Ms B complained that, since October 2021, the Council had not adhered to a communications protocol agreed with her. We found there were several occasions when the Council failed to comply with the protocol causing Ms B distress and inconvenience. In recognition of the injustice caused, the Council has …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
22-001-113 — Medway Council
Summary: Mrs X complained that the Council failed to effectively search for a suitable care placement for her mother, Mrs P. She says the family felt pressured to accept an unaffordable placement. The Council undertook a thorough search for a placement for Mrs P. However, ultimately, it was at fault …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-017-826 — Bournemouth, Christchurch and Poole Council
Summary: Mrs X complained that the Council communicated poorly with her and her family about paying for her mother’s care, finding and arranging assessments at care homes, and when her mother was in hospital. Mrs X said the delay arranging a residential care home placement resulted in her mother going …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
23-013-092 — London Borough of Lewisham
Summary: Ms X complained the Council reduced care and support hours for her adult son, Mr Y, without any reassessment of his needs or a review of his care and support plan when he went into supported living accommodation. The Council was at fault which caused Ms X and Mr …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-008-582 — London Borough of Tower Hamlets
Summary: Mrs X’s representative complained about the cancellation of a cleaner; failure to find a new personal assistant; failure to consider a requested reasonable adjustment and failure to refund her client contribution. She says this has caused stress, anxiety and worsened her health conditions. There is no evidence of fault …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-020-031 — Worcestershire County Council
Summary: We will not investigate this complaint about the Council’s assessment of Miss X’s mental capacity and its decision to authorise a Deprivation of Liberty Safeguards (DoLS). The Council is reviewing the assessment and further investigation by us would not lead to a different outcome. If Miss X remains unhappy …
LGO (Local Government & …
Adult Care Services
May 2024
23-020-833 — London Borough of Lewisham
Summary: We will not investigate this late complaint about the Council’s decision to move Mr Y to emergency accommodation in 2022. There is not a good reason for the delay in the matter being brought to our attention.
LGO (Local Government & …
Adult Care Services
May 2024
23-013-280 — Brighton & Hove City Council
Summary: Ms M complained the Council failed to address her concerns about the adult care services her son, Mr S, receives. The Council is at fault for delay reviewing Mr S’s care plan and failing to carry out a transport assessment.
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
23-014-185 — Leeds City Council
Summary: The Council delayed in completing Mr X’s support plan following a Care Act assessment, failed to advise him at the outset that direct payments could not be used to pay a relative to act as his personal assistant because she was living in the same household and reversed its …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-006-417 — Dudley Metropolitan Borough Council
Summary: We will not investigate Mx Y’s complaint about how the Council completed a review of their adult social care needs. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Oct 2024
24-017-927 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about Council’s decision to limit Mr X’s participation in the co-production board. The Council has since met with and written to Mr X to resolve his ongoing concerns.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-017-462 — Derby City Council
Summary: Miss X complained about a lack of support to complain about a care worker, and about a failure to allocate a named social worker to her case. We will not investigate this complaint because it is unlikely that an investigation would find evidence of fault in the Council’s actions.
LGO (Local Government & …
Adult Care Services
Jun 2025
24-012-888 — Hampshire County Council
Summary: Ms Y, on behalf of Mr X, complained about the Council’s handling of his care and support needs, as well as its failure to oversee the completion of a housing adaptation, leaving the work unfinished. We find the Council at fault for failing to respond to contact, properly consider …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-022-964c — South West Yorkshire Partnership NHS Foundation Trust (24 …
Summary: Mrs X complained about the care provided to her daughter Miss Y when she had a mental health crisis. The events occurred in 2022. We will not investigate the complaint because it is out of time.
LGO (Local Government & …
Health
Jul 2025
24-022-964b — NHS West Yorkshire ICB - Calderdale (24 022 …
Summary: Mrs X complained about the care provided to her daughter Miss Y when she had a mental health crisis. The events occurred in 2022. We will not investigate the complaint because it is out of time.
LGO (Local Government & …
Health
Jul 2025
24-022-964a — Beechwood Medical Centre (24 022 964a)
Summary: Mrs X complained about the care provided to her daughter Miss Y when she had a mental health crisis. The events occurred in 2022. We will not investigate the complaint because it is out of time.
LGO (Local Government & …
Health
Jul 2025
25-002-334 — Royal Borough of Kingston upon Thames
Summary: We will not investigate this complaint about how the Council supported Miss X as a care leaver. This is because we could not add to any previous investigation by the Council and Miss X’s injustice caused by any fault there was, has already been remedied. In addition, we cannot …
LGO (Local Government & …
Adult Care Services
Aug 2025
23-013-813a — Livewell Southwest (23 013 813a)
Summary: Mrs X complained on behalf of the Y family that Plymouth City Council and Livewell Southwest did not put support in place, recommended by an independent social worker. We consider they missed opportunities to consider Miss Y’s ability to make decisions about her support. The Council delayed arranging a …
LGO (Local Government & …
Health
Upheld
Sep 2025
25-003-962 — Surrey County Council
Summary: We will not investigate this complaint about a best interests decision which determined where Miss B’s son should live. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Oct 2025
25-003-237 — Liverpool City Council
Summary: We will not investigate this complaint about a carer’s assessment completed by the Council and the support it then offered. There is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Nov 2025
24-021-321 — London Borough of Waltham Forest
Summary: The Council was at fault for poor communication and a failure to properly review Mr X’s care needs after his reablement package ended. It was also at fault for the significant delay in responding to his complaint. The Council has agreed to apologise to Mr X and make a …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2025
25-003-785 — Kingston Upon Hull City Council
Summary: We will not investigate this complaint about funding of adult social care. We are satisfied with the actions the Council has taken in response to the complaint. It has accepted fault, apologised for the distress caused and waived over £400 of client contribution. The Council has explained its calculations.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2025
24-003-905 — East Riding of Yorkshire Council
Summary: Mrs X complained that the Council failed to take adequate action when she raised concerns about her late mother’s health and living conditions despite having knowledge of her history of mental health problems and hoarding behaviours. We found no grounds to criticise the Council’s actions. However, it was at …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
201103669 — Tayside NHS Board
Mrs C made a number of complaints about the board's care and treatment of her husband (Mr C). Mr C had been diagnosed with rectal cancer (cancer of the lower part of the large bowel) and liver metastasis (cancer that spreads to other parts of the body). Mrs C said …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2013
NIPSO-201916274 — GP
We investigated whether an increase in a man’s prescription caused him to attend hospital the following day. We found the Practice’s increase in the dose fell within the prescribed limits.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Mar 2024
21-016-545 — East Riding of Yorkshire Council
Summary: Mr X complained about the way the Council handled his mother, Mrs Y’s care and finances. The Council failed to review Mrs Y’s care plan and package when concerns were raised for her wellbeing and failed to ensure care improved after it identified failings in the care provider. The …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
21-016-886 — Liverpool City Council
Summary: Ms X complained the Council failed to review or properly communicate with her about her direct payments and support needs. Ms X says this has caused her anxiety, confusion and put her to the time and trouble of complaining. The Council was at fault for not reviewing or communicating …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
22-009-143 — Royal Borough of Greenwich
Summary: We will not investigate Mr B’s complaint about the Council contacting him when he told it not to. This is because
LGO (Local Government & …
Adult Care Services
Nov 2022
Domestic Homicide Reviews(320)— showing 50 strongest matches
Cheltenham — recommendation GASC.4
Where individuals are reluctant to engage with Registered Social Workers specifically, alternative social care practitioners may provide support to the individual under the direction of an appropriately qualified lead worker.
Gloucestershire Adult Social Care
Doncaster — recommendation 2
That all agencies provide assurances and evidence to Safer Stronger Doncaster Partnership that all known risk factors and vulnerabilities such as alcohol use, are taken into consideration, and that contact with victims of domestic abuse is undertaken in cognisance and with agreement of the victim.
Safer Stronger Doncaster Partnership
West Lancashire — recommendation 23
WLCSP to seek assurances through the ICB that all GP Practices operating within West Lancashire are reminded of key points which are already recommended practice. To include the following: Read coding and recording Dealing with incoming letters Dealing with non- attendances by adults with care and support needs (the “vulnerable”) …
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
West Lancashire — recommendation 3
WLCSP encourages all agencies that have formed part of this Panel to appoint a specific point of contact to report back to WLCSP on progress against the implementation of the above 'trauma informed' recommendations.
Lancashire Constabulary | West Lancashire Community …
Lancashire Constabulary
Gloucester — recommendation 6
Probation services to identify a Women’s SPOC in Gloucestershire LDU in line with BGSW CRC’s policy in relation to working with female offenders.
BGSW CRC
Kent — recommendation 1
That someone diagnosed with dementia should be offered a one-to-one discussion shortly after diagnosis so that their hopes, wishes, fears concerns can be recorded in an assessment that can be referred to throughout the duration of their illness. This can be updated as circumstances change.
Kent and Medway ICB
NHS Kent and Medway …
Lincoln — recommendation 10
• The LSAB should assure itself that all partner agencies ensure that adults who are described as lacking communication should have an advocate in line with their Human Rights and the Care Act 2014.
LSAB | partner agencies
Lincoln — recommendation 9
The LSAB should assure itself that: • All partner agencies promote the rights of adults with care and support needs and all those covered by the Care Act 2014, to have their communication skills enhanced ensuring a person-centred approach; And, • Partner agencies enable all practitioners to feel confident to …
LSAB | partner agencies
Lincoln — recommendation 6
LSAB should seek assurance from Adult Social Care: • The MCA is being applied appropriately and that the view that some adults lack capacity overall is challenged; • That the process supporting best interest decision making is clearly understood and effective.
LSAB | Adult Social Care
Lincoln — recommendation 4
Where Adult Safeguarding action is being considered for an adult with care and support needs, and that individual is assessed at that moment as lacking capacity to take part or provide a view about their circumstances and wishes, there needs to be some reflection about who represents those needs and …
LSAB | partners
Pembrokeshire — recommendation 27
Welsh Government should establish a national taskforce to develop a strategic and system wide approach to improving responses to older people in order to ensure that the experiences and needs of older people are taken fully into account in national strategy and policy, good practice is disseminated and that any …
Welsh Government
Welsh Government
Pembrokeshire — recommendation 15
Co-design an information campaign with older people that is aimed at increasing older people and the general publics’ awareness and recognition of abuse and where/how to access information and support locally. This information should be made available in community settings accessed by older people e.g. GP surgeries, pharmacies, libraries, community …
Regional VAWDASV Board
Pembrokeshire — recommendation 14
Ensure that the needs of older people experiencing domestic abuse, in particular those living in rural areas are fully taken into account in the review of the regional Violence against Women, Domestic Abuse and Sexual Violence strategy
Regional VAWDASV Board
Pembrokeshire — recommendation 13
Commission a service/services that can provide a bespoke, tailored service to respond to the needs of older people who are experiencing domestic abuse
Pembrokeshire County Council
Pembrokeshire County Council
Swindon — recommendation 13
That where a victim of domestic abuse discloses criminal offences a record is made of their preferred outcome.
Wiltshire Police
Wiltshire Police
Swindon — recommendation 10
In consultations where details of sexual relations are being discussed, Clinicians should consider including a question such as "and are you comfortable with that?" which would give the patient the opportunity to disclose any concerns they might have about their relationship(s) without causing offence in cases where there were none.
Swindon GP Practices | Swindon ICB
NHS Bath and North …
Somerset — recommendation 6
All agencies need to take into consideration the client’s wishes and risk concerns around recommended safety plans offered by professionals, with particular understanding that the client will understand the perpetrators patterns of behaviour the most. Where possible, these wishes should be accommodated in options provided.
Bournemouth Churches Housing Association | Knightstone …
West Berkshire — recommendation 14
A greater recognition should be given to family involvement in developing treatment plans especially when the service focus is inpatient avoidance, families views and history must be included in planning effective community based care.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
West Berkshire — recommendation 7
The admission system should more fully support allocating of contacts to a team or group of individuals, versus contact with a new staff member for each service contact, to promote consistency in the response and to ensure that a trusting relationship may be developed.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
West Berkshire — recommendation 6
We recommend that health and social care professionals must wherever possible seek the views of an appropriate individual, for example spouse, carer, other relative and that this principle should be incorporated into health and social care professionals ongoing training and development.
Health and social care professionals
Herefordshire — recommendation 9
Provide clear guidance to ensure that patients and carers are offered and consistently reminded of a clear single point of contact at whatever level they are engaged, and that appropriate supporting information is given regarding planned interventions and indications for contacting services before crisis.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Chiltern — recommendation WWA Recommendation 4
Wycombe Women’s Aid Leadership Team to consider further ways of engaging with clients who are hard to reach.
Manager Wycombe Women’s Aid
Chiltern — recommendation SMART Recommendation
Targeted and proactive outreach work should be employed with service users identified as having multiple and complex needs.
SMART– Service Manager
Cardiff — recommendation 3
All social care staff should ensure that the voice of the individual at the heart of the assessment should be heard. This should ensure that they are interviewed in their own right, and also alone if felt to be appropriate or necessary.
Adult Social Services
Adult Social Services
Herefordshire — recommendation 12
Provide clear guidance to ensure that patients and carers are offered and consistently reminded of a clear single point of contact at whatever level they are engaged, and that appropriate supporting information is given regarding planned interventions and indications for contacting services before crisis.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Herefordshire — recommendation 2
Trust to look at ways of ensuring that information leaflets for carers of patients with a diagnosis of dementia is given to all carers, in order that they are aware of how to access help if required.
Wye Valley NHS Trust
Wye Valley NHS Trust
North Tyneside — recommendation 2
Community Safety Partnership to work with Safeguarding Adults Board to ask Partners to review their policy and procedures when clients default from service provision (Do Not Attend) to ensure that the vulnerability of the patient is taken into consideration when deciding what action (if any) needs to be taken.
Community Safety Partnership | Safeguarding Adults …
Safeguarding Adults Board
North Tyneside — recommendation 1
North Tyneside CCG advise all partners to discuss the overall vulnerability of adult patients when considering what follow up actions should be taken in the case of DNAs in any area of the partnership.
North Tyneside ICB
Harlow — recommendation 15.10.5
Where a victim of domestic abuse is likely to come across their perpetrator and/or their known associates within a statutory setting, a request to change an appointment time should never be dismissed as “not allowed” or impossible to do. All government agencies have a duty to respond appropriately if domestic …
All Agencies
Harlow — recommendation 15.6.1
The Housing Dept. should continue with face to face interviews with clients presenting themselves as “at risk” whenever possible. However it is noted that there is a telephone response service for all out of hours contact and this does not allow a more personalised approach to anyone presenting as homeless. …
Harlow Council Housing Department
Epping Forest — recommendation 12.2
All Mental Health Service staff to continue to make attempts to obtain collaborative information and to indicate in progress notes the reason for not obtaining collaborative information from families and carers.
NELFT
North East London NHS …
Somerset — recommendation 7.2.4
When dealing with sleep problems there should be evidence of a more holistic assessment e.g., including mental health and social circumstances as well as a pain review.
NHS Somerset ICB
NHS Somerset ICB
Norfolk — recommendation 22
That the Mental Health Trusts roll-out of DIALOG and DIALOG+ system be maintained and reviewed, and in due course audited to ensure social, cultural, familial, and other patient -based information can be built into care in Norfolk more effectively.
Norfolk & Suffolk Foundation NHS Trust
Norfolk and Suffolk NHS …
Lincoln — recommendation 10.4.1
Adult Care should put in place effective measures to ensure that assessment and case management activity promotes holistic assessments of the person's needs, strengths and outcomes which puts the person at the centre of the intervention and supports them to live safely in their environment.
Lincolnshire County Council Adult Care
Norfolk — recommendation IMR_NCHC_3
Share with clinical leadership team and continue within training and telephone support for trust staff, the need to hear the patient’s voice at all consultations, face to face and on telephone.
Norfolk Community Health & Care NHS …
Norfolk Community Health & …
Nottingham — recommendation 11.2
Agencies should consider whether individuals dealing with multiple disadvantages can be offered “open appointments” where it is safe to do so. Experience shows that services can then be reactive when individuals require input, particularly at a point of crisis.
All Agencies
Nottingham — recommendation 11.1
All Agencies should review their policies for discharging people, to ensure that there is not a “one strike and you’re out” ethos. This would help people who present as high risk and struggle to engage with services on a consistent basis.
All Agencies
Nottingham — recommendation 10.2a
Where procedures outline expected discharge actions there is enough flexibility within services to respond differently when necessary.
Nottingham Recovery Network
North Yorkshire — recommendation 5
In high risk cases of domestic abuse, professionals within a support role should consider the benefits of making direct face to face contact with the victim rather than on the telephone. This should not be discontinued simply because the victim does not consent. Ideally this would be a joint home …
All agencies involved in the DHR
Nottingham — recommendation 20.6.1
All WAIS staff should have a process within their service handbook on how to gain information from case notes and staff members working with a woman to prevent too many staff members contacting the woman and her having to repeat her ‘story’.
Women’s Aid Integrated Services
Merton — recommendation 6.1
All agencies working with victim and survivors of domestic abuse should ensure they understand what is being said and if necessary arrange translation services. This will ensure the victim/survivors have the best knowledge available that they understand.
Merton Community Safety Partnership
Torbay — recommendation 7
Patients with complex needs are liable to exhibit a high rate of “Did Not Attends”, this should be seen as evidence of complexity rather than evidence of lack of willingness to engage.
Torbay Council | Devon and Cornwall …
Torbay Council
Flintshire — recommendation 17.26
We recommend that supervision and training across the multi-agency network, including training of ancillary and reception staff, emphasises the importance of a listening approach and aims at ensuring that staff keep in the forefront of their minds the courage it takes to ask for help and to report abuse. (Community …
Community Safety Partnership
Flintshire — recommendation 15.90
Training needs to help practitioners explore the complexity of working in the area of personal relationships and to raise awareness of the conflicts of loyalty which exist for the victim when reporting abuse or considering ending relationships. (North Wales Regional Training Consortium)
North Wales Regional Training Consortium
Flintshire — recommendation 15.85
Professionals should be trained to recognise that tools are frameworks for the collection of information and to assist in assessment but they are not the complete assessment of risk; which should be a dynamic process involving the collection and evaluation of all the relevant information available, including the voices of …
North Wales Regional Training Consortium
Stockport — recommendation 8
Pennine Care NHS Foundation Trust : Ensure that clinical decisions about changes to pathways or services should include the care team, and there is evidence that the perspectives of patient and carers have been considered, taken into account and documented
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Bexley — recommendation 1
When a physical health condition is identified as having an impact on activities of daily living, a referral to occupational therapy would be recommended to assess for appropriate support for patient to manage their daily activities.
Dartford and Gravesham NHS Trust
Dartford and Gravesham NHS …
Bexley — recommendation 4
Review policies regarding care of patients with disabling conditions to ensure that conversations about support and care needs are introduced when the symptoms impact daily living.
Dartford and Gravesham NHS Trust | …
Dartford and Gravesham NHS …
Bexley — recommendation 2
NHS England to ensure that health professionals giving a terminal diagnosis organise for immediate support to be available to patients to discuss the impact of their illness and the prognosis on their life, and the support likely to be needed and available.
NHS England
NHS England
Wycombe — recommendation 13
All Services involved in Review are to verify that there is currently support for those engaging with their service if they cannot read or write. If this provision is not currently in place, steps are to be taken to include such support in the relevant policies and procedures.
Thames Valley Police | Oxford Health …
Thames Valley Police
CQC enforcement actions(18)
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, telling it to make urgent improvements. This followed an inspection in March which found a decline in the quality of care provided, …
Oct 2025
Warning Notice: Tameside Hospital NHS Foundation Trust
The Care Quality Commission reviewed information and visited the trust on 9 March 2011, finding that care was falling short of essential standards in three areas, including safe and appropriate care and meeting individual dietary needs. CQC is requiring Tameside …
May 2011
Warning Notice: Barts Health NHS Trust
The Care Quality Commission told Barts Health NHS Trust that it must improve patient care and support given to staff at the Royal London Hospital. This followed an unannounced inspection in June where the hospital was found to be not …
Royal London Hospital
Sep 2013
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) conducted an inspection of inpatient wards for people with a learning disability or autistic people at Lanchester Road Hospital and Bankfields Court, operated by Tees, Esk and Wear Valleys NHS Foundation Trust. Following the inspection, …
Lanchester Road Hospital in Durham and Bankfields…
Oct 2022
Warning Notice: East Sussex Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to East Sussex Hospitals NHS Trust, requiring urgent improvements to patient care. Inspectors found insufficient staff to support proper patient care in some areas, and that care plans and risk assessments …
Jun 2011
Warning Notice: United Lincolnshire NHS Trust
Following a visit to Pilgrim Hospital, the Care Quality Commission found United Lincolnshire NHS Trust was not taking appropriate steps to ensure people receive effective, safe and appropriate care. Inspectors noted that care plans did not always reflect patient needs, …
Pilgrim Hospital
Mar 2011
Warning Notice: Liverpool University Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) told Liverpool University Hospitals NHS Foundation Trust to take immediate action to improve the safety of some of its services following two inspections. Inspectors found a lack of effective systems to ensure all patients received …
Jan 2021
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission demanded that Kent and Medway NHS and Social Care Partnership Trust take action to improve services following a review in November 2010. The review found that two hospitals, William Harvey Hospital in Ashford and a KMPT …
Mar 2011
Warning Notice: Cambridgeshire Community Services NHS Trust
CQC told Cambridgeshire Community Services NHS Trust it must make urgent improvements to comply with two national standards of quality and safety at its children’s inpatient services based at Hinchingbrooke Hospital. This followed an unannounced inspection on 3 September 2013, …
Holly Ward at Hinchingbrooke Hospital, Hinchingbr…
Oct 2013
Warning Notice: Bedford Hospital NHS Trust
The Care Quality Commission (CQC) issued formal warnings to Bedford Hospital NHS Trust following unannounced inspections in July 2013. CQC found the trust was not meeting national standards of quality and safety, specifically regarding staffing levels and the care and …
Bedford
Aug 2013
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) served Essex Partnership University NHS Foundation Trust with a warning notice following an inspection of two acute wards for adults of working age. The inspection raised serious concerns about patient safety, including staff not always …
acute wards for adults of working age
Apr 2023
Warning Notice: Lincolnshire Partnership NHS Foundation Trust
The Care Quality Commission told Lincolnshire Partnership NHS Foundation Trust that it must take action to improve the care of those accessing its specialist mental health and learning disability services. Reports identified areas for improvement including the safety and suitability …
Mar 2011
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission (CQC) has told Mid Essex Hospital Services NHS Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection at Broomfield Hospital in Chelmsford, Essex, which found …
Broomfield Hospital, Chelmsford, Essex
May 2013
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission has issued a warning notice to Mid Essex Hospital Services NHS Trust. This action was taken after concerns were raised around the flow of patients through the A&E department, whether care was being provided soon enough, …
Broomfield Hospital at Chelmsford
Aug 2015
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission has formally warned Medway NHS Foundation Trust that it needs to improve the care it provides to patients in the emergency department at Medway Maritime Hospital, Gillingham. CQC issued warning notices to the trust after an …
Medway Maritime Hospital, Gillingham
Mar 2014
Warning Notice: Lewisham and Greenwich NHS Trust
The Care Quality Commission (CQC) carried out an unannounced, focused inspection at Queen Elizabeth Hospital in December after receiving information that triggered concerns about the safety and quality of services relating to DNACPR orders. CQC told Lewisham and Greenwich NHS …
Queen Elizabeth Hospital
Jan 2021
Warning Notice: Colchester Hospital University NHS Foundation Trust
During an inspection in September and October 2015, CQC inspectors found Colchester Hospital University NHS Foundation Trust needed to make a number of urgent improvements. Following this, CQC issued a letter to the trust highlighting the urgent improvements required to …
Jan 2016
Warning Notice: Chesterfield Royal Hospital NHS Foundation Trust
The Care Quality Commission (CQC) has told Chesterfield Royal Hospital NHS Foundation Trust it must make urgent improvements to comply with the national standards of quality and safety. This follows an unannounced inspection where inspectors found that people were not …
Chesterfield, Derbyshire
Aug 2013