Nursing and midwifery crisis
Inadequate recruitment and retention of nursing and midwifery staff due to lack of comprehensive bursary schemes.
Source spread
Where this theme appears
This theme appears across 12 independent accountability sources, so the source mix matters as much as the headline total.
29 inquiry recs
13 PFD reports
76 committee recs
81 CQC actions
1 NAO rec
1 PHSO rec
4 IMB recs
2 Article 2 learning points
12 PHSO decisions
128 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(29)
F192 — Strong nursing voice
Recommendation: The Department of Health and Nursing and Midwifery Council should introduce the concept of a Responsible Officer for nursing, appointed by and accountable to, the Nursing and Midwifery Council.
Gov response: Accepted in principle. The aim of the recommendation, which is to have a role that is accountable for providing assurance to the Nursing and Midwifery Council that nurses are meeting professional standards and are keeping …
Accepted in part
R31 — Staffing and skills mix review
Recommendation: Health Boards should ensure that the staffing and skills mix is appropriate for each ward, and that it is reviewed in response to increases in the level of activity/patient acuity and dependency in the ward. Where the clinical profile of …
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
F213 — Training standards for healthcare support workers
Recommendation: Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute a nationwide system to protect patients and care receivers from harm. This system should be supported by fair …
Gov response: Not accepted, however we intend to achieve the intention behind this by ensuring that organisations have the right staff with the right skills to deliver care in a safe way. We do not believe that …
Not accepted
F212 — Training standards for healthcare support workers
Recommendation: The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other …
Gov response: Not accepted, however we intend to achieve the intention behind this by ensuring that organisations have the right staff with the right skills to deliver care in a safe way. This recommendation is a step …
Not accepted
F211 — Training standards for healthcare support workers
Recommendation: There should be a common set of national standards for the education and training of healthcare support workers.
Gov response: Accepted. The National Minimum Training Standards for healthcare support workers were published in March 2013. The Cavendish Review has also made a number of recommendations to improve the national standards on education and training, including …
Accepted
F210 — Code of conduct for healthcare support workers
Recommendation: There should be a national code of conduct for healthcare support workers.
Gov response: Accepted. Skills for Health and Skills for Care published a national code of conduct for healthcare support workers and adult social care workers in March 2013. The Cavendish Review recommends that Skills for Health and …
Accepted
F209 — Registration of healthcare support workers
Recommendation: A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are …
Gov response: Not accepted, however we intend to achieve the intention behind this by ensuring that organisations have the right staff with the right skills to deliver care in a safe way. The Government understands that the …
Not accepted
F208 — Strengthening identification of healthcare support workers and nurses
Recommendation: Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.
Gov response: Accepted in principle. We agree that patients should be clear on the role of people caring for them, for example through identity labels, clear job titles and uniforms. Many organisations already do this. However, the …
Accepted in part
F207 — Strengthening identification of healthcare support workers and nurses
Recommendation: There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.
Gov response: Accepted in principle. This is a complex issue as healthcare support workers carry out a number of different tasks in varied roles, so a uniform description can be difficult. The Cavendish Review80 recommends that once …
Accepted in part
F206 — Strengthening the nursing professional voice
Recommendation: The effectiveness of the newly positioned office of Chief Nursing Officer should be kept under review to ensure the maintenance of a recognised leading representative of the nursing profession as a whole, able and empowered to give independent professional advice …
Gov response: Accepted. The Chief Nursing Officer for England provides professional leadership for all nurses, midwives and care staff across the healthcare system. The Chief Nursing Officer is also the principal advisor to the Government on all …
Accepted
F205 — Strengthening the nursing professional voice
Recommendation: Commissioning arrangements should require the boards of provider organisations to seek and record the advice of its nursing director on the impact on the quality of care and patient safety of any proposed major change to nurse staffing arrangements or …
Gov response: Accepted in principle. Compassion in Practice, the vision and strategy for nursing in England, asks Boards to sign off and publish staffing levels. NHS England has asked that decisions on quality improvement plans are signed …
Accepted in part
F190 — National standards
Recommendation: There should be national training standards for qualification as a registered nurse to ensure that newly qualified nurses are competent to deliver a consistent standard of the fundamental aspects of compassionate care.
Gov response: Accepted in part. The Nursing and Midwifery Council already sets national standards for undergraduate degrees, but Health Education England and NHS England, in collaboration with the Nursing and Midwifery Council and the universities, will work …
Accepted in part
F187 — Practical hands-on training and experience
Recommendation: There should be a national entry-level requirement that student nurses spend a minimum period of time, at least three months, working on the direct care of patients under the supervision of a registered nurse. Such experience should include direct care …
Gov response: Accepted. In its initial response to The Inquiry, Patients First and Foremost, the Government committed to a pilot programme, whereby every student who seeks NHS funding for nursing degrees will serve up to a year …
Accepted
F186 — Practical hands-on training and experience
Recommendation: Nursing training should be reviewed so that sufficient practical elements are incorporated to ensure that a consistent standard is achieved by all trainees throughout the country. This requires national standards.
Gov response: Accepted. The Nursing and Midwifery Council has already taken steps to address this. The Nursing and Midwifery Council published new standards for all pre-registration nursing programmes in 2010 which must be followed at all the …
Accepted
COVID-M3.5 — Scale Up Urgent and Emergency Care
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, in conjunction with organisations responsible for delivering services, should plan for surge capacity in urgent and emergency care during a pandemic. Plans must ensure that there is sufficient workforce …
Gov response: The government agrees with the Inquiry that it is important to continue to prepare to scale up urgent and emergency care capacity.
Accepted in part
F204 — Strengthening the nursing professional voice
Recommendation: All healthcare providers and commissioning organisations should be required to have at least one executive director who is a registered nurse, and should be encouraged to consider recruiting nurses as non-executive directors.
Gov response: Accepted in part. All provider organisations have at least one executive director who is a registered nurse. NHS England has the Chief Nursing Officer on its executive board, and director level (although not executive level) …
Accepted in part
F203 — Strengthening the nursing professional voice
Recommendation: A forum for all directors of nursing from both NHS and independent sector organisations should be formed to provide a means of coordinating the leadership of the nursing profession.
Gov response: Accepted. The Chief Nursing Officer has established the Federation of Nurse Leaders, a national forum that has been established to raise the awareness and profile of the nursing voice at a national level. Its membership …
Accepted
F202 — Strengthening the nursing professional voice
Recommendation: Recognition of the importance of nursing representation at provider level should be given by ensuring that adequate time is allowed for staff to undertake this role, and employers and unions must regularly review the adequacy of the arrangements in this …
Gov response: Accepted. Implementation is a matter for local employers and unions. The Royal College of Nursing, UNISON and NHS Employers have endorsed this recommendation and will work with providers and commissioners to try to ensure that …
Accepted
F201 — Strengthening the nursing professional voice
Recommendation: The Royal College of Nursing should consider whether it should formally divide its "Royal College" functions and its employee representative/trade union functions between two bodies rather than behind internal "Chinese walls".
Gov response: Accepted The Royal College of Nursing has given careful consideration to whether it should split its trade union and professional functions and has decided that it should not. The Royal College of Nursing believes it …
Accepted
F200 — Key nurses
Recommendation: Consideration should be given to the creation of a status of Registered Older Person's Nurse.
Gov response: Accepted in part. The Department and its system partners have considered this recommendation and feel there are better ways of improving nursing care for older people. Caring for older people is core to the job …
Accepted in part
F199 — Key nurses
Recommendation: Each patient should be allocated for each shift a named key nurse responsible for coordinating the provision of the care needs for each allocated patient. The named key nurse on duty should, whenever possible, be present at every interaction between …
Gov response: Accepted. The Secretary of State for Health announced his support for patients having a named nurse in July 2013 and we are working with NHS England to support the delivery of this aim. As The …
Accepted
F197 — Nurse leadership
Recommendation: Training and continuing professional development for nurses should include leadership training at every level from student to director. A resource for nurse leadership training should be made available for all NHS healthcare provider organisations that should be required under commissioning …
Gov response: Accepted in part. Healthcare organisations have a responsibility to ensure that their staff and teams are appropriately trained and continuously developed: having properly trained staff is one of the requirements they have to meet to …
Accepted in part
F196 — Nurse leadership
Recommendation: The Knowledge and Skills Framework should be reviewed with a view to giving explicit recognition to nurses' demonstrations of commitment to patient care and, in particular, to the priority to be accorded to dignity and respect, and their acquisition of …
Gov response: Accepted. Employers have the freedom to use the Knowledge and Skills Framework to develop their own local arrangements to ensure that dignity, respect and leadership is fully reflected in staff training and development and that …
Accepted
F195 — Nurse leadership
Recommendation: Ward nurse managers should operate in a supervisory capacity, and not be office-bound or expected to double up, except in emergencies as part of the nursing provision on the ward. They should know about the care plans relating to every …
Gov response: Accepted in principle. There needs to be local flexibility in delivering nursing care, so the Government are not mandating that ward nurse managers must operate solely in a supervisory capacity. However, in the initial Government …
Accepted in part
F194 — Standards for appraisal and support
Recommendation: As part of a mandatory annual performance appraisal, each Nurse, regardless of workplace setting, should be required to demonstrate in their annual learning portfolio an up-to-date knowledge of nursing practice and its implementation. Alongside developmental requirements, this should contain documented …
Gov response: Accepted in principle. We consider that the aim of the recommendation, which is to have a role that is accountable for providing assurance to the Nursing and Midwifery Council that nurses can show they are …
Accepted in part
F193 — Standards for appraisal and support
Recommendation: Without introducing a revalidation scheme immediately, the Nursing and Midwifery Council should introduce common minimum standards for appraisal and support with which responsible officers would be obliged to comply. They could be required to report to the Nursing and Midwifery …
Gov response: Accepted in principle. In advance of the introduction of revalidation by the Nursing and Midwifery Council, NHS Employers will: • support NHS organisations in ensuring they have a clear link between the values in the …
Accepted in part
F189 — Consistent training
Recommendation: The Nursing and Midwifery Council and other professional and academic bodies should work towards a common qualification assessment/examination.
Gov response: Accepted in principle. The Nursing and Midwifery Council is responsible for setting the UK-wide standards for all pre-registration nursing and midwifery education. These standards underpin all pre- registration nursing and midwifery education so that education …
Accepted in part
F188 — Aptitude test for compassion and caring
Recommendation: The Nursing and Midwifery Council, working with universities, should consider the introduction of an aptitude test to be undertaken by aspirant registered nurses at entry into the profession, exploring, in particular, candidates' attitudes towards caring, compassion and other necessary professional …
Gov response: Accepted in principle. The Government’s Mandate to Health Education England contained a requirement to ensure that selection into all new NHS funded training posts incorporates testing of values. In addition, NHS England is working with …
Accepted in part
BRIS-185 — Review and apply 1991 paediatric nurse staffing standards as minimum
Recommendation: The 1991 standards for the numbers of paediatrically qualified nurses required at any given time should serve as the minimum standard and should apply where children are treated (save in emergencies). The standards should be reviewed as a matter of …
Unknown
Prevention of Future Deaths reports(13)
Wendy Telfer
Concerns: The coroner noted insufficient training for physical healthcare staff regarding mental health needs and the application of the Mental Health Act. Concerns were also raised about the persistent lack of available psychiatric beds, which caused delays in patient transfer.
Response (Northern Eastern and Western Devon NHS Trust): • The CCG monitors delayed discharge data from mental health wards through local boards and contract review meetings. • Devon Partnership NHS Trust (DPT) has temporarily repurposed rehabilitation unit capacity … (AI summary)
Response (Royal Devon and Exeter NHS Trust): • The Royal Devon and Exeter NHS Trust stated that its Liaison Psychiatry Team provided formal training on the Mental Health Act (MHA) to at least 496 staff in 2016, … (AI summary)
Response (Devon Partnership NHS Trust): • The Trust established a central bed management team, secured additional contracted bed capacity, and extended the operational times of Crisis Resolution and Home Treatment teams. • The Trust implemented … (AI summary)
Responded
Harrison Hassall
Concerns: The coroner raised concerns that newly qualified midwives may be permitted to work in the community without sufficient experience, noting this issue is not exclusive to one trust.
Response (Department of Health and Social Care): • Investigations by University Hospitals of Leicester NHS Trust and East Midlands Ambulance Service NHS Trust identified areas for improvement and resulted in recommendations for action. • The identified actions … (AI summary)
Responded
Rodney Gates
Concerns: The coroner raised concerns regarding the failure to undertake required patient observations, which was linked to low nursing staff numbers, reliance on agency nurses, and a lack of staff experience and equipment on the ward.
Response (Medway Maritime Hospital): • The Trust implemented electronic observation recording and a NEWS2-based red flagging system across all inpatient wards. • The Trust increased nursing staff establishment following a review and reduced agency … (AI summary)
Responded
Elizabeth Robinson
Concerns: The coroner noted insufficient nursing staff levels impacted patient supervision and nurses' ability to take full breaks. Furthermore, front-line nursing staff had not received the findings of the internal investigation into the patient's death.
Response (Aneurin Bevan University Health Board): • The Health Board established a Health Care Support Worker pool in September 2020 and employed an additional 145 WTE HCSWs to support enhanced care. • A full acuity audit … (AI summary)
Responded
Margaret Kinsey
Concerns: The coroner identified challenges in the Emergency Department due to a lack of night-time consultant cover and insufficient supervision for junior doctors, especially those new to the department. The report also noted inconsistent documentation of supervisory discussions between clinicians.
Overdue
Angela O’Donnell
Concerns: The coroner noted concerns regarding the hospital trust's reliance on agency nursing staff and sought information on measures to reduce this dependence. They also inquired about national plans to address the ongoing shortage of nursing staff.
Response (Frimley Park Hospital): • The Trust reduced its nursing vacancy rate from 13.7% in April 2019 to 8.9% in October 2021 through various recruitment initiatives, including international recruitment and apprenticeship routes. • It … (AI summary)
Overdue
Manhareen Kaur
Concerns: Babies at increased risk of early neonatal collapse following complicated deliveries are not provided with enhanced monitoring on the postnatal ward, leading to a lack of early detection should collapse occur.
Overdue
Charlotte Warkcup
Concerns: The coroner raised concerns regarding the safety of standalone midwife-led birthing centres versus those with immediate hospital access, along with the recruitment and retention of midwives to ensure continuity of care, and the improved detection of babies who are of small gestational age.
Response (Department of Health and Social Care): • The Department invested £165 million since 2021 to grow and support the maternity workforce and improve neonatal care. • The Government committed to expanding midwifery training places by 3,650 … (AI summary)
Responded
Arthur Trott
Concerns: The JRCALC guidance for footling breech presentations is insufficiently robust, leading to delays in transferring mothers to hospital. There is also a lack of consultant midwives providing obstetric support, guidance, and training within ambulance services.
Overdue
Teegan Barnard
Concerns: The coroner raised concerns about the failure to exclude bilateral tension pneumothoraces during cardiac arrest and delayed recognition of surgical emphysema. There were also gaps in the anaesthetic department's post-death investigation and the Trust's system for triggering death investigations.
Response (NHS England): • NHS England reviewed the response from University Hospitals Sussex NHS Foundation Trust and consulted with the Resuscitation Council UK. • The National Patient Safety Team will share learnings from … (AI summary)
Response (Royal College of Anaesthetists): • The Royal College of Anaesthetists stated it would share learning about bilateral pneumothoraces as a cause of cardiac arrest via SALG's Patient Safety Update and educational events. • The … (AI summary)
Response (Royal College of Anaesthetists): • The Royal College of Anaesthetists stated it would share learning regarding bilateral pneumothoraces as a cause of cardiac arrest in the absence of trauma or thoracic surgery via SALG's … (AI summary)
Response (CQC): • The CQC contacted the Trust and reviewed provided documents in response to the PFD report. • The CQC intends to establish regular engagement meetings with the Trust to monitor … (AI summary)
Response (St Richards Hospital): • The Trust ensured relevant multi-disciplinary team members received training in managing obstetric emergencies, including maternal collapse scenarios. • The management of tension pneumothorax, including the significance of facial swelling … (AI summary)
Response (NHS England): • Health Education England (HEE) stated that the specific concerns regarding clinical care and the Trust's investigation did not fall within its current role and statutory responsibilities. • HEE is … (AI summary)
Responded
Luca Yates
Concerns: Planned changes to paediatric specialist training will reduce experience in Level 3 Neonatal units. This may lead to less practical experience for middle grades in neonatal resuscitation and a lower level of experience for future consultant general paediatricians.
Response (Royal College of Paediatrics and Child Health): • The Progress+ curriculum includes mandatory key capabilities for neonatal care and resuscitation skills, which trainees acquire through time in neonatal settings and simulation. • The curriculum mandates safe non-invasive … (AI summary)
Responded
John Seagrove, Pauline Humphris and Patricia Steggles
Concerns: The coroner noted a resurgence of ambulances queuing outside the ED, with 15-20 waiting on occasions. Additionally, concerns were raised about 'burn-out' among healthcare staff and difficulties in recruiting to vacant positions.
Response (Department of Health and Social Care): • The department published a 'Delivery plan for recovering urgent and emergency care services' to improve waiting times. • Ambulance services received £200 million in additional funding in 2023/24, maintained … (AI summary)
Responded
Elizabeth Roberts
Concerns: The coroner noted residual staffing shortages in the District Nursing Service at Tameside and Glossop Integrated Care and NHS Foundation Trust, which require a national change of approach to resolve.
Response (Department of Health and Social Care): • NHS England developed a national Community Nursing Safer Staffing Tool to support providers in identifying appropriate staffing levels. • Greater Manchester Integrated Care Board was asked to discuss the … (AI summary)
Responded
Select committee recommendations(76)— showing 50 strongest matches
#28 —
Recommendation: NHSE&I acknowledged that COVID-19 has had a disproportionate impact on Black, Asian and minority ethnic (BAME) staff and admitted that there is variability in how well these staff have been supported during the pandemic. In response to our questions 64 …
Response attribution not verified
#27 —
Recommendation: NHSE&I noted that over 32,000 nurses stepped up to support the NHS during the COVID-19 outbreak, including former nurses and over 20,000 students. However, it acknowledged that there needs to be better local systems for retaining these returners, such as …
Response attribution not verified
#25 —
Recommendation: NHSE&I acknowledged that there are worrying signs of stress and burnout amongst NHS staff since the COVID-19 outbreak. It cited figures from a Nursing Times survey, 56 C&AG’s Report, para 2.6. Based on England-domiciled applicants, UK universities, and includes midwifery …
Response attribution not verified
#24 —
Recommendation: In December 2019, the government announced the introduction of a new maintenance grant for nursing students from September 2020, which consists of a non-repayable grant of £5,000 to £8,000 to help with living costs. Students will still pay their own …
Response attribution not verified
#23 —
Recommendation: Since 2017, the number of people accepted onto nursing and midwifery degree courses has increased from 22,045 in 2017 to 23,060 in 2019. This still means that, in 2019, only 430 (2%) more people accepted a place on a nursing …
Response attribution not verified
#22 —
Recommendation: The policy change impacted on some students and regions more than others. For example, from 2016 to 2018, there was a 10% increase in the number of students accepted onto nursing degree courses for children’s nursing and for applicants from …
Response attribution not verified
#21 —
Recommendation: From 2017, the Department changed the funding arrangements for nursing, midwifery and allied health professional students. Prior to 2017, HEE paid tuition fees to universities and NHS bursaries to students to cover their living costs. Instead, these students moved onto …
Response attribution not verified
#9 —
Recommendation: The Department acknowledged that the demand for nurses and the extent of nurse shortages vary between specialisms and regions.14 For example, in the period July– September 2019, NHS trusts in England reported an overall nursing vacancy rate of 12%, but …
Response attribution not verified
#8 —
Recommendation: It is essential that the NHS understands not just how many nurses it needs, but where and in what specialisms. However, the NAO and other stakeholders have noted that the NHS Long Term Plan contained service commitments that did not …
Response attribution not verified
#7 —
Recommendation: NHSE&I told us that the advent of COVID-19 meant that workforce planning over a horizon of three to four years was not currently possible, and at the moment the main focus of the system was on winter planning. It thought …
Response attribution not verified
#6 —
Recommendation: The COVID-19 outbreak presents new challenges, as well as opportunities, for improving the recruitment and retention of nurses in the NHS. In particular, it is vital that the NHS protects the mental health and well-being of nurses who have contributed …
Response attribution not verified
#5 —
Recommendation: The removal of the NHS bursary in 2017 signally failed to achieve the Department’s ambition to increase nursing student numbers. From 2017, the Department changed the funding arrangements for nursing, midwifery and allied health professional students. It removed the NHS …
Response attribution not verified
#4 —
Recommendation: The nursing needs of social care remain an unaddressed afterthought for the Department of Health & Social Care. Vacancies for nurses in social care have increased from a rate of 4.1% in 2012–13 to 9.9% in 2018–19, while the number …
Response attribution not verified
#3 —
Recommendation: We are not convinced that the Department has plans for how the NHS will secure 50,000 more nurses by 2025. The Department plans to meet the 50,000 commitment by increasing the domestic supply of registered nurses, recruiting from overseas and …
Response attribution not verified
#2 —
Recommendation: With 8 out of 10 midwives reporting that they did not have enough staff on their shift to provide a safe service, it is clear that urgent action is needed to address staffing shortfalls in maternity services. Evidence submitted to …
Response attribution not verified
#11 — Require Government to commit to safe maternity staffing and continuity of carer target.
Recommendation: The Government must give firm commitments in the refreshed Long Term Workforce Plan to deliver safe staffing levels for maternity services. Without this, safe and sustainable maternity care will remain out of reach. As part of the workforce plan the …
Response attribution not verified
#10 — Maternity workforce shortages remain a significant barrier to safe care provision.
Recommendation: Workforce shortages remain a major barrier to safe maternity care, despite recent recruitment progress. We are disappointed the Government suspended its continuity of carer target, which is especially important for marginalised women, including Black women, who face greater challenges in …
Response attribution not verified
#29 — Set out specific measures to reduce burnout and improve pay for CMHS staff.
Recommendation: Staff retention is important for continuity of care for people with SMI. As part of the forthcoming 10 Year Workforce Plan, the Government should set out specific measures to reduce burnout, including action on caseload management and access to supervision; …
Response attribution not verified
#26 —
Recommendation: The Royal College of Nursing noted that, to retain nurses who worked during the pandemic, it will be essential to provide access to specialised mental health support, carry out risk assessments for staff and ensure people are able to take …
Response attribution not verified
#32 —
Recommendation: We recommend again, that Health Education England publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years including an assessment of whether sufficient numbers are being trained. We further recommend that …
Response attribution not verified
#31 —
Recommendation: It is clear that workforce planning has been led by the funding envelope available to health and social care rather than by demand and the capacity required to service that demand. Furthermore, there is no accurate, public projection of what …
Response attribution not verified
#16 —
Recommendation: We repeat our recommendation that HEE must be required (whether in its own right or as part of NHS England) to publish objective, transparent and independently-audited annual reports on workforce projections that cover the next five, ten and twenty years, …
Response attribution not verified
#13 —
Recommendation: This Committee’s September 2020 report, NHS nursing workforce, concluded that there was a risk that the NHS was focusing on short-term pressures at the expense of the 23 C&AG’s Report, page 30 24 Qq 69, 75 25 NHS0043 NHS Providers …
Response attribution not verified
#16 —
Recommendation: We have been raising concerns about the lack of long-term planning for the NHS workforce since well before the COVID-19 pandemic52. We have noted that among comparable OECD countries the UK has relatively low numbers of nurses and doctors per …
Response attribution not verified
#2 —
Recommendation: We remain very concerned about the critical shortages across the NHS workforce and the Department’s repeated delays in publishing a strategy to address them. Workforce shortages are widespread across the NHS, and particularly acute in some specialisms, for example midwifery. …
Response attribution not verified
#2 —
Recommendation: Continuity of carer is a cornerstone of the Government and NHS commitment to deliver safer maternity services for all women. It is simply not possible to implement it safely, however, due to the considerable staffing shortages across maternity services. A …
Response attribution not verified
#24 — NHS Long Term Workforce Plan addresses projected shortfall of up to 360,000 staff.
Recommendation: In the workforce plan, NHS England estimates that over a 15-year period, without action, there would be a shortfall of 260,000 to 360,000 staff by 2036–37. NHS England explained that, because it takes time to train people and that they …
Response attribution not verified
#30 — Significant workforce shortfall of medical microbiologists and virologists undermines NHS infection control.
Recommendation: Another challenge relates to the NHS workforce. There is a shortfall of professionals in this area, including of medical microbiologists and virologists.77 According to the Royal College of Pathologists, there is a 20% shortfall in consultant medical microbiologists and a …
Response attribution not verified
#3 — Introduce comprehensive bursary scheme for nursing and midwifery students, guaranteeing NHS work.
Recommendation: The Government’s current target of recruiting 50,000 NHS nurses is not having any meaningful impact on the true scale of nursing shortages. The Government must introduce a new bursary scheme comprising full coverage of tuition fees, a non-means- tested grant …
Response attribution not verified
#13 — Require the Department to update and publish the RCOG maternity staffing tool.
Recommendation: We urge the Department to update and publish the tool produced by RCOG in time for the rollout of the upcoming refreshed Workforce Plan, so that every maternity unit can use it to plan effectively, ensure appropriate staffing and deliver …
Response attribution not verified
#12 — Suspension of RCOG safe staffing tool undermines maternity workforce stability.
Recommendation: Suspending adoption of RCOG’s safe staffing tool has left Trusts without clear guidance on safe staffing levels, perpetuating poor workforce supply and undermining efforts to stabilise and support maternity teams. (Conclusion, Paragraph 64) 33
Response attribution not verified
#34 —
Recommendation: As well as boosting NHS capacity and meeting the needs of local communities, health centres could act as new ‘anchor’ sites for high streets and bring in more people to the local high street.
Response attribution not verified
#19 —
Recommendation: The Department and HEE highlighted the important role that apprenticeships and nursing associates play in widening access to the nursing profession, by enabling people to earn money as they train. In the case of nursing associates, which is a separate …
Response attribution not verified
#1 —
Recommendation: On the basis of a Report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department), NHS England and NHS Improvement (NHSE&I) and Health Education England (HEE) on the NHS nursing …
Response attribution not verified
#22 —
Recommendation: We further recommend that workforce reports be undertaken in consultation with the Devolved Administrations to ensure that a clear picture is given on the health and care workforce throughout the United Kingdom. (Paragraph 88) Additional powers for the Secretary of …
Response status not verified
#21 —
Recommendation: We therefore recommend that the Government include in the Bill, provisions to require Health Education England to publish objective, transparent and independent annual reports on workforce shortages and future staffing requirements that cover the next five, ten and twenty years …
Response status not verified
#20 —
Recommendation: We do not believe that the duty to publish an update on the roles and responsibilities once every five years is an adequate response to workforce shortages that are endemic in the NHS. We are very sympathetic to the detailed …
Response status not verified
#30 —
Recommendation: The way that the NHS does workforce planning is at best opaque and at worst responsible for the unacceptable pressure on the current workforce which existed even before the pandemic. (Paragraph 183) 58 Workforce burnout and resilience in the NHS …
Response attribution not verified
#16 —
Recommendation: We recommend that the Department develops an NHS and social care national policy framework around migration to support national and local workforce planning and identify the balance between domestic and international recruitment in the short, medium and long-term. (Paragraph 91) …
Response attribution not verified
#17 —
Recommendation: We recommend that the Government undertake an urgent review of short-term recruitment and retention issues within the health and care workforce, including productivity improvements, sharing of best practice through data, removal of professional demarcation, use of technology, additional training places …
Response attribution not verified
#15 —
Recommendation: We note that the Government decided to resist an amendment to the Health and Care Bill that would have required it to publish independently verified assessment of health, social care and public health workforce numbers at least once every two …
Response attribution not verified
#21 —
Recommendation: Among comparable OECD countries the UK has relatively low numbers of hospital beds, nurses and doctors per 1,000 population and also carries out relatively low numbers of advanced diagnostic examinations.46 NHSE&I told us that it would take two to three …
Response attribution not verified
#10 —
Recommendation: Between 2010 and 2019 the NHS saw an average annual growth in emergency admissions of more than 3% and in urgent cancer referrals from GPs of more than 10%. Although there was relatively strong growth in the number of consultants …
Response attribution not verified
#3 —
Recommendation: The NHS will be less able to deal with backlogs if it does not address longstanding workforce issues and ensure the existing workforce, including in urgent and emergency care and general practice, is well supported. NHSE&I believes it will be …
Response attribution not verified
#18 —
Recommendation: The Government need to publish an evidence-based plan, supported by up-to-date workforce modelling, setting out how it will increase the capacity and sustainability of all sectors of the specialist palliative and end of life care workforce, as part of the …
Response attribution not verified
#17 —
Recommendation: Current shortages in the specialist workforce are putting palliative care services in an unsustainable position which threatens their ability to deliver equitable and high-quality palliative and end of life care. Extensive consultant vacancies, impending retirements, limited training places and widespread …
Response attribution not verified
#22 —
Recommendation: The Government must work with the Royal College of Nursing to ensure that menstrual health is included in the standard training offer for all nurses. The renewed Women’s Health Strategy must include this as an objective together with a clear …
Response attribution not verified
#21 —
Recommendation: We were dismayed to learn that training modules in menstrual and gynaecological health for nurses are very limited and typically undertaken only by those who choose to “specialise” in women’s health. Nurses are at the frontline of sexual and reproductive …
Response attribution not verified
#2 — Provide Committee with update on reducing NHS staff shortfalls and improving retention rates.
Recommendation: NHS England’s improvement plans rely on better staff recruitment and retention to address significant shortfalls in the NHS workforce, but we are not convinced that NHS England’s current approach will achieve its very optimistic assumptions. NHS England has identified a …
Response attribution not verified
#9 — Require Government to publish funded maternity workforce plan matching RCOG staffing levels within six months.
Recommendation: There is an urgent need for a robust and funded maternity-wide workforce plan, which must be delivered without further delay. The Government must commit to funding, recruiting, and retaining the workforce at the level set out by the forthcoming report …
Response attribution not verified
CQC inspection actions(81)— showing 50 strongest matches
Worthing Hospital
The trust must ensure there are enough nursing staff to keep patients safe.
Must Do
University Hospital of Hartlepool
The service must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people’s care and treatment needs.
Must Do
The York Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
The York Hospital
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must Do
The York Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced midwives to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for …
Must Do
The Princess Royal Hospital
The trust should ensure nursing and healthcare assistant staffing levels are as planned.
Should Do
Southport & Formby District General Hospital
The trust should continue to act to address the high number of registered and unregistered nursing vacancies.
Should Do
Scarborough Hospital
The trust must ensure that there are sufficient allied healthcare professional, nursing, and medical staff to keep people safe.
Must Do
Scarborough Hospital
The service must ensure that there are enough midwifery and medical doctors to meet minimum staffing levels and they should mitigate against the risks of short staffing.
Must Do
Salford Royal Hospital
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Salford Royal Hospital
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Salford Royal Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Salford Royal Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Salford Royal Hospital
The service must deploy sufficient numbers of suitably qualified nursing and support staff to keep patients safe.
Must Do
Salford Royal Hospital
The trust must ensure that there are sufficient numbers of nursing and medical staff that can meet people's care and treatment needs and keep them safe from avoidable harm.
Must Do
Rochdale Infirmary
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Rochdale Infirmary
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Princess Royal Hospital
The trust must ensure there are enough nursing staff and medical staff to keep patients safe. This needs to include arrangements for the management of patients operated on by Royal Sussex County Hospital surgeons.
Must Do
Pilgrim Hospital
The trust should continue to work towards increasing the number of midwives who are competent in theatre recovery to ensure women are recovered by appropriately skilled staff.
Should Do
Pilgrim Hospital
The trust should ensure they provides sufficient numbers of nursing and medical staff to safely support patients.
Should Do
Northwick Park Hospital
The trust should ensure that there are enough nursing and support staff on every shift to keep patients safe.
Should Do
Lister Hospital
The service must ensure all steps are taken to appropriately manage and maintain safe staffing in the maternity unit.
Must Do
Ellesmere Port Hospital
The trust should ensure that there are sufficient numbers of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Should Do
Ellesmere Port Hospital
The trust should ensure that there are sufficient numbers of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Should Do
Ellesmere Port Hospital
The trust must ensure that nurse staffing levels, are safe for the numbers of patients in the department.
Must Do
Ealing Hospital
The trust should ensure that there are enough nursing and support staff on every shift to keep patients safe.
Should Do
Doncaster Royal Infirmary
The trust must ensure they have enough staff with the right qualifications, skills, training, and experience to keep women safe from avoidable harm and to provide the right care and treatment.
Must Do
Doncaster Royal Infirmary
The trust must ensure it has enough nursing, medical and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Must Do
Doncaster Royal Infirmary
The trust must ensure the service’s medical and nursing staff match the planned numbers. They must also ensure the service has enough medical staff with appropriate skill mix on each shift.
Must Do
Crowborough Birthing Centre
The service should ensure they have enough maternity staff deployed to keep women and birthing people safe from harm.
Should Do
St Benedict's Hospice
The service must ensure that nurse staffing meets national guidance.
Must Do
St Benedict's Hospice
The service must ensure there are enough qualified midwives to meet minimum staffing levels and improve compliance with one-to-one care in labour. Community midwives escalated into the hospital must receive an induction to the area(s) they are required to cover.
Must Do
Fairfield General Hospital
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Fairfield General Hospital
The trust must ensure that any shortfalls in midwifery staffing have mitigations in place to ensure safe levels.
Must Do
Windsor Dialysis Unit
Thetrustshouldworktoreducethenumberofoccasionsthemidwiferyledunitissuspendedforfourhoursormore.
Should Do
Windsor Dialysis Unit
Employsufficientmaternitystafftoensurethattheservicemeetsthetrust'sownassessedrequirementsas submittedintheMaternityBirthratePlusandreport2018.
Should Do
Victoria Infirmary
Take actions to improve nurse staffing levels across all medical wards.
Must Do
UHBW Bristol Campus
The service should ensure there are enough midwifery staff to provide a full range of maternity choices including use of the midwifery-led unit.
Should Do
Salisbury District Hospital
Consider the impact of midwifery staffing challenges on resourcing the quality and safety agenda in maternity.
Should Do
Royal Sussex County Hospital
The trust should continue their efforts to address the nursing and medical workforce challenges.
Should Do
Royal Sussex County Hospital
The trust must monitor nurse staffing levels using an acuity-based staffing tool to ensure there are always enough nurses in the emergency department.
Must Do
Royal Derby Hospital
Ensure there enough suitably qualified midwifery staff to ensure safety.
Must Do
North Tyneside General Hospital
The service should continue to monitor the sickness rate for nursing and midwifery staff in maternity and continue to follow the trust sickness policy to support and manage staff appropriately and meet the trust target of 4.0%.
Should Do
Milton Keynes Hospital
The trust should continue to address the vacancy and sickness rates in maternity staffing.
Should Do
James Paget Hospital
The service must ensure there are enough midwifery and medical staff with the right qualifications, training, and experience to keep women and pregnant people safe from avoidable harm and provide the right care and treatment.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure there are enough qualified midwives to meet minimum staffing levels and improve compliance with one-to-one care in labour. Community midwives escalated into the hospital must receive an induction to the area(s) they are required to cover.
Must Do
Bridlington Hospital
The service must ensure that sufficient numbers of suitably qualified, competent, skilled and experienced registered nursing staff are deployed across the medicine wards on the Scarborough Hospital site to promote safe care and treatment of patients.
Must Do
Berwick Infirmary
The service should continue to monitor the sickness rate for nursing and midwifery staff in maternity and continue to follow the trust sickness policy to support and manage staff appropriately and meet the trust target of 4.0%.
Should Do
Bedford Hospital
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced midwives to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for …
Must Do
IMB individual recommendations(4)
Bronzefield (2025)
How does NHS England plan to address the shortage of experienced nurses in Bronzefield (6.1, 6.5)?
NHS / Healthcare Provider
In Progress
Brook House (2020)
Keep staff recruitment and retention as a priority.
NHS / Healthcare Provider
Berwyn (2020)
Overnight nursing cover
NHS / Healthcare Provider
Implemented
Styal (2023)
Staff shortages have impacted on women’s access to healthcare and hospital visits, especially the need for escorts to enable access to internal and external appointments. This is particularly critical given the different demands in the female estate for gynaecological services, paediatric care, and pre-and post-natal treatment. What additional support can be provided to female prisons to help them meet this …
HMPPS
Health investigations(7)
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 12
Nursing leadership and historically high churn rates within the nursing team is a known risk to the Trust for this service. A contingency plan should be in place for managing the risks incurred when senior positions in the team are vacant to ensure stability on the unit. The practice of …
london
An Independent Review into the care and treatment provided by … — Rec 4
The Trust must work with its current and future workforce levels to recognise, adapt to and manage the safety challenges that a staffing shortfall may pose, including ensuring the stability of nursing staff. The Trust must develop a representative, competent and culturally sensitive workforce which is supported to provide services …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Independent investigation: Valerie Thomas, Cardiff (2005) — Rec 6
A review of the staffing made available to the CMHTs within Cardiff and Vale NHS Trust should be undertaken. In particular the number of medical, nursing and social work staff and the provision of a broader range of support staff and services should be considered. The guidelines referred to in …
wales
Independent investigation: Michael Galloway, Illingworth (1999) — Rec 6.3
The panel recommends that in conjunction with the commissioners of the service, the Trust should review the key nurse system, and support it with appropriate training.
north_east_yorkshire
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 13
A robust strategy for monitoring the Recruitment and Retention of all staff in the FIPT Service, especially Waddon Ward, should be produced and monitored monthly and include the involvement of the MDT. This strategy should include meaningful feedback from staff that leave the service and must be fed back into …
london
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 4b
Health Boards must address immediate staffing pressures while national workforce specifications for maternity services are redeveloped. Health Boards must undertake a comprehensive review of obstetric workforce capacity taking account of service complexity, links with gynaecology, geography, and workforce sustainability. Health Boards should review midwifery and neonatal nursing staffing levels and …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 4a
A multidisciplinary maternity workforce planning tool should be developed and implemented to align and integrate with BAPM standards for neonatal services. This tool should cover the full maternity pathway and include adequate provision for allied health professionals, psychology and pharmacy, as well as services for women with additional social and …
wales
Accepted
Article 2 learning points(2)
— LP 9
We further recommend that Holloway agrees a minimum staffing level and takes action when the level in any area and/or at any time is not reached.
The Governor
Accepted
— LP 8
We recommend that the adequacy of staffing levels is reviewed particularly in respect of the needs of women at weekends. We also recommend that stronger efforts are made to ensure residential units are not deprived of staff because of bed watches.
HMPPS
Accepted
Independent reviews(8)
Darzi Review — Rec 23
It is apparent from this report and from the accompanying analysis that the NHS is in critical condition. It continues to struggle with the aftershocks of the pandemic. Its managerial capacity and capability have been degraded, and the trust and goodwill of many frontline staff has been lost. The service …
Health & Social Care
Darzi Review — Rec 20
Staff engagement. Too many staff are disengaged. There is also compelling evidence that, post-pandemic, too many staff have become disengaged, and there are distressingly high-levels of sickness absence – as much as one working month a year for each nurse and each midwife working in the NHS. The experience of …
Health & Social Care
Willis Commission on Nursing 2012 — Rec 18
A national nursing career framework must be implemented urgently by all partners and properly resourced. It should be based on the four governments' existing policies of building career frameworks and pathways that support movement between, and synthesis of, practice, management, education and research; that value and reward different career paths; …
Health & Social Care
Willis Commission on Nursing 2012 — Rec 8
The public needs to know what it can expect of registered nurses educated at degree level. Stakeholders should scale up recruitment campaigns and other measures, including dialogue with the media, to promote better understanding of contemporary nursing and nursing education and dispel the myth that better educated nurses are less …
Health & Social Care
Willis Commission on Nursing 2012 — Rec 28
A long-term, sustainable funding model should be developed across the UK to support the education and training of future nurses, including adequate financial support for students and bursaries to support mature students.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 1
Evidence of the positive impact of registered nurses on patient outcomes must be utilised by healthcare providers in planning the nursing skill mix.
Health & Social Care
Cavendish Review — Rec 9
The NMC should make caring experience a prerequisite to starting a nursing degree, and review the contribution of vocational experience towards degrees so that staff with strong caring experience can undertake ‘fast-track’ degrees. Skills for Care should work with Higher Education Institutions to look at how care experience can be …
Health & Social Care
Cavendish Review — Rec 7
HEE and the LETBs should develop new bridging programmes into pre-registration nursing and other health degrees from the support staff workforce in health and social care, working with Skills for Care, NMC and Skills for Health; and explore the Barchester proposal for a Higher Apprenticeship.
Health & Social Care
PHSO casework decisions(12)
P-003181 — A practice in the Newham area
Mr B complained staff failed to monitor his father, who pulled out his oxygen tube, leading to low oxygen, infections, pain, and potentially hastening his death.
NHS in England
Dec 2024
P-002450 — Sandwell and West Birmingham Hospitals NHS Trust
Ms A complained about her mother's poor nursing care on a stroke ward, citing issues with transfer, communication, staff attitude, hygiene, responsiveness, general care, dignity, and complaint handling.
NHS in England
Feb 2024
P-002489 — Homerton Healthcare NHS Foundation Trust
Miss I complained about poor nursing care, inadequate oxygen supply, staff unawareness of patient needs, and a lack of compassion and communication during her son's hospital stay.
NHS in England
Mar 2024
P-002496 — Gateshead Health NHS Foundation Trust
Ms A complained the Trust did not properly assess her father’s continence and falls risk, leading to him falling and his oxygen dislodging, which she believes led to his death.
NHS in England
Upheld
Mar 2024
P-003186 — Oxford University Hospitals NHS Foundation Trust
Miss U complained about poor hospital care for her late partner, including bad food, delayed discharge, unanswered call bells, poor communication, and lost belongings.
NHS in England
Dec 2024
P-001871 — Manchester University NHS Foundation Trust
Ms G complained the Trust failed to ensure Mr K wore splints, delayed medication, ignored weight loss, provided poor mouth care, and delayed hospital treatment for pneumonia.
NHS in England
Mar 2023
P-003334 — University Hospitals Sussex NHS Foundation Trust
Mrs A complained the Ambulance Trust delayed dispatching an ambulance. She also alleged the hospital Trust failed to provide pain relief, delayed surgery, didn't treat a bowel blockage, and moved her husband's body without informing her.
NHS in England
Feb 2025
P-001858 — Lancashire Teaching Hospitals NHS Foundation Trust
Mrs M complained about poor care and treatment for her father, Mr L, including long waits, dehydration, wrong milk, rude staff, missing hearing aids, and denied/delayed visits before his death.
NHS in England
Mar 2023
P-001933 — South Tyneside and Sunderland NHS Foundation Trust
Miss D complained about delayed medication, poor pressure care, insufficient mental health support, and basic nursing failings for her father, which she believed contributed to his avoidable death.
NHS in England
Apr 2023
P-003082 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Norfolk Trust delayed treatment, gave incorrect antibiotics, and discharged his partner too soon. Queen Elizabeth Trust provided poor nursing care, delayed investigations/treatment, and had poor communication.
NHS in England
Oct 2024
P-003083 — George Eliot Hospital NHS Trust
Staff delayed checking preoperative samples, discharged partner without treatment for a broken hip, gave no condition updates, prohibited family visits, and didn't assist with bed transfers.
NHS in England
Oct 2024
P-003177 — Mid Yorkshire Teaching NHS Trust
Mrs C complained about poor staff communication, delayed referral to a complex needs team, failure to use a CPAP machine, poor nursing care, and inadequate complaint handling.
NHS in England
Upheld
Nov 2024
LGO / SPSO decisions(128)
202403956 — Lothian NHS Board - Acute Services Division
C’s parent (A) suffered a number of falls during an admission to hospital where A sustained a head injury and subsequently died. C complained to the board that A’s falls risk was not effectively managed. The board identified some failings in relation to A’s falls care, including a lack of …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2026
201102885 — Lanarkshire NHS Board
Mr A was an elderly man with a history of health problems and restricted mobility. He had been nursed at home for several years. Mr A was admitted to hospital with confusion, infection and back pain. Nine days after admission, he developed pressure ulcers. Mr A remained in the hospital …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2012
201104145 — Tayside NHS Board
Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later. Her daughter, Miss …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201303065 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C, who is an advice worker, complained on behalf of her client, Ms B. Ms B's late fiancé (Mr A) had died a few days after being admitted to Glasgow Royal Infirmary with severe jaundice. Ms B had told Ms C that the board provided inadequate nursing care, and …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2014
201406562 — Grampian NHS Board
Mr C complained about the care provided to his late father (Mr A) at Aberdeen Royal Infirmary. Mr A was blind, elderly and frail. He had cancer. Early in 2014 he had had many emergency admissions to hospital and in May 2014 he was admitted again. During his stay he …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201403869 — Greater Glasgow and Clyde NHS Board - Acute …
Miss C's father (Mr A) was admitted to Glasgow Royal Infirmary from another hospital where he had been admitted earlier following a fall at home. Mr A was admitted to A&E and then moved to a ward. Mr A died several days after his admission. Miss C was concerned that …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2015
201500611 — Grampian NHS Board
Ms C and her cousin (Mr A), complained about the care and treatment Mr A's late mother (Mrs A) received at Kincardine Community Hospital. Mrs A had dementia and had been admitted to Kincardine Community Hospital from Aberdeen Royal Infirmary for a period of rehabilitation following a fall at home. …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201508221 — Grampian NHS Board
Miss C complained about the community nursing care provided to her late mother (Mrs A) who was elderly. Miss C said that the community nurse undertook a procedure which caused Mrs A severe distress and brought her to the point of collapse. Miss C said that she and her mother …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2016
201508844 — Lothian NHS Board
Mr C complained about the medical and dental care and treatment he received from the prison health centre. He suffered from severe pain, particularly head and face pain, due to historic injuries and he raised concerns that adequate pain relief was not provided to him and that nursing staff regularly …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2016
201601079 — Lanarkshire NHS Board
Mrs C complained that her mother (Mrs A) was left sitting in a chair for nine hours without access to a bed, whilst waiting to be moved to a new ward. Mrs C said that Mrs A had asked to go to bed during this time. The board told us …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2016
201508619 — Lothian NHS Board
Mrs C complained to us about the medical care and treatment provided to her late father (Mr A) at the Western General Hospital before his death. Mr A had previously been diagnosed with rheumatoid arthritis associated interstitial lung disease (a group of disorders characterized by inflammation and scarring of the …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2016
201600669 — Forth Valley NHS Board
Ms C, who works for an advocacy and support agency, complained on behalf of Mr B regarding the care and treatment provided to Mr B's father (Mr A) during his admission to Forth Valley Royal Hospital. Ms C complained that Mr A's falls risk was not appropriately assessed on two …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jan 2017
201508155 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C's father (Mr A) was admitted to the Queen Elizabeth University Hospital. Mr A died there several days later. Mr C complained to us about Mr A's nursing and medical care and treatment during his admission. We obtained independent advice from a nurse and a consultant in the care …
SPSO (Scottish Public Se…
Health
Upheld
May 2017
201603071 — Forth Valley NHS Board
Mr C complained about the care his late wife (Mrs A) received from nursing staff during two admissions to Forth Valley Royal Hospital. On the first occasion she was admitted with sepsis (a blood infection) and on the second occasion she was admitted with a hip fracture. In particular, Mr …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2017
201802151 — Highland NHS Board
Ms C complained about the nursing care her mother (Mrs A) received at Raigmore Hospital. Mrs A suffered from osteoporosis (weak or fragile bones) and fell during an admission to the hospital. A number of weeks following her discharge from hospital, Mrs A's GP arranged for x-rays to be taken …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2018
201800220 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C, who works for an advocacy and support agency, complained on behalf of her client (Ms B) about the care and treatment provided to Ms B's daughter (Ms A) at Glasgow Royal Infirmary. Ms A was admitted to the hospital on two occasions due to complications from her gastric …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2019
201701267 — Lothian NHS Board
Mr C complained about the care provided to his wife (Ms A) during a home birth, in particular that two midwives did not attend at the same time. We took independent advice from a midwife. We found that it was standard practice for one midwife to attend first and that …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2019
201803694 — Dumfries and Galloway NHS Board
Mrs C complained about the nursing care and treatment given to her late husband (Mr A) at Dumfries and Galloway Royal Infirmary. She also complained that communication by the board was poor. Mr A had a complicated medical history. As he began to experience an increase in symptoms, he was …
SPSO (Scottish Public Se…
Health
Upheld
May 2019
201707447 — Lanarkshire NHS Board
Mr C complained about the nursing care and treatment his father (Mr A), who had dementia, received when he was admitted to University Hospital Monklands. He also complained that Mr A had been unfit for discharge on the day of his planned discharge. In addition, Mr C complained about the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2019
201809208 — Lothian NHS Board - Acute Division
C complained on behalf of their late parent (A) regarding nursing and medical care and treatment provided to A during an admission to the Western General Hospital. We took independent advice from a nurse and from a consultant in general medicine and care of the elderly. With regard to the …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
202101294 — Fife NHS Board
C complained about the care and treatment provided to their late parent (A) by the board. A had dementia and was experiencing worsening delirium following a urinary tract infection. A was admitted to hospital by an out-of-hours doctor who visited A at home. C's sibling accompanied A in the ambulance …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2023
202106438 — Glasgow City Health and Social Care Partnership
C complained about the care and treatment provided to their parent (A) who had dementia. C believed nursing staff had failed to provide A with a reasonable standard of care. They complained that A had been confined to bed inappropriately and that no assessment had been made of the impact …
SPSO (Scottish Public Se…
Health and Social Care
Partly Upheld
Sep 2023
202104942 — Grampian NHS Board
C, an advocate, submitted a complaint on behalf of the family of A. A was a resident of a care home and attended hospital with low potassium levels. A later sustained a leg fracture around the time of the first discharge and was re-admitted to hospital. A later died. C …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2023
202208181 — Fife NHS Board
C complained on behalf of their spouse (A) about the care and treatment provided by the board before they died. A was an end of life patient having been diagnosed with incurable lung cancer. A developed symptoms likely caused by an obstruction of one of the major blood vessels attached …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2024
202109772 — Grampian NHS Board
C complained about the nursing care that their parent (A) received. A had dementia and was admitted following a fall in their care home, remaining in hospital until their death some weeks later. C complained that during A’s admission, A was not treated with dignity, that they were left without …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2024
202202485 — Golden Jubilee National Hospital
C complained about the care and treatment provided to their spouse (A). A stayed in critical care wards after surgery and acquired wounds to their back and shoulders. C complained that A’s wounds were not appropriately documented or treated. In response to C’s complaint, the board acknowledged that documentation of …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2024
202201376 — Tayside NHS Board
C complained about the care and treatment provided to their parent (A). A had been admitted to hospital before being transferred to a mental health facility. A then developed abdominal symptoms, which required them to be transferred to an acute hospital for treatment. A had been considered for surgery, but …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2024
202201215 — Fife NHS Board
C’s spouse (A) was admitted to hospital following a stroke. A remained in hospital for several weeks before transferring to another hospital. A later died. C complained to the board about A’s hospital stay and raised concerns about wound management, fall pain management and the identification of hip and shoulder …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2024
202306916 — Tayside NHS Board
C complained about the nursing care provided to their late spouse (A) during their admission to hospital. C raised specific concerns about the personal care and stoma care provided. We took independent advice from a nurse. We found that the personal care provided to A was reasonable. However, we identified …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2024
202306836 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board failed to provide them with reasonable care and treatment. C has a rare demyelination condition (an inflammatory condition that affects the brain and spinal cord) which impacts them both physically and mentally. C is also unable to see clearly and struggles to concentrate. C complained …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2024
202301731 — Forth Valley NHS Board
C complained about the nursing care and treatment provided to their parent (A) who was admitted to hospital after a fall. We took independent advice from a registered nurse. We found that there were unreasonable time gaps between care and comfort checks, making it impossible for the board to provide …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2024
202301629 — Fife NHS Board
C complained about the nursing care provided to their late parent (A) in hospital. A had been transferred from another health board for rehabilitation having suffered a stroke. C said that there was infrequent care rounding and that the provision of and monitoring of A’s diet, nutrition and fluid intake …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2024
202301101 — Dumfries and Galloway NHS Board
C complained about the medical and nursing care and treatment provided to their late parent (A). A was admitted to hospital after repeated falls at home. A’s behaviour changed significantly during their admission which suggested that their mental state was deteriorating. C said that they were not directly informed of …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2024
202209316 — Fife NHS Board
C complained about the care and treatment that their sibling (A) received whilst in hospital following a fall. C also raised complaints about communication issues with the board. The board accepted that there had been poor communication with A’s family but did not indicate any concern regarding the care and …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2025
202404349 — Highland NHS Board
C complained about the care and treatment provided to their late parent (A). A was admitted to hospital due to a nose bleed that would not stop. During admission, A used a hospital trolley to cross the ward to the toilet. A jug of water spilt from the trolley and …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025
202402836 — Borders NHS Board
C complained about the lack of care and understanding for their parent (A) who died in hospital. C referred to incorrect information being passed to the family and the lack of notes and records of events which occurred during A's admission. C said that while the board replied with some …
SPSO (Scottish Public Se…
Health
Aug 2025
202309879 — Forth Valley NHS Board
C’s spouse (A) who had prostate cancer was admitted to the Clinical assessment unit (CAU) of the hospital following a few days of deteriorating health. During their admission, A remained in the CAU for three days before leaving the building without staff being aware of this. A contacted C in …
SPSO (Scottish Public Se…
Health
Upheld
Aug 2025
202305480 — Fife NHS Board
C complained about the nursing care provided to their late parent (A) whilst in hospital. They complained about a lack of adherence to infection control, poor staff attitude and breaches of uniform policy. C also complained that A had been issued a zimmer frame without appropriate assessment and guidance, and …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2025
202401362 — Lothian NHS Board - Acute Services Division
C complained about the nursing care provided to their late parent (A) during their admission to hospital. A arrived at the emergency department before being admitted to a ward. While in hospital, A lost weight and had difficulty eating. Due to delirium, A’s mobility was poor and they experienced a …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2025
201100825 — Tayside NHS Board
Mr C's mother (Mrs A) required ankle replacement surgery. Around one week after her surgery, Mrs A was discharged home. Mr C complained that his mother was not properly cared for by the district nursing service to the extent that her ankle became severely infected, and she was disorientated and …
SPSO (Scottish Public Se…
Health
Partly Upheld
Feb 2012
201101188 — Western Isles NHS Board
Mrs C made a number of complaints about the care and treatment provided to her mother (Mrs A) when she was admitted to the Western Isles Hospital for two days. We found that although staff had recorded that Mrs A was allergic to plasters, they continued to apply them to …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2012
201101177 — Tayside NHS Board
Mr C made a number of complaints about the care and treatment he received in Ninewells Hospital. He had been admitted following a hernia operation at another hospital. At Ninewells, he was found to have a haematoma (bruise) and there was also some evidence of infection. We found that Mr …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2012
201102383 — Greater Glasgow and Clyde NHS Board - Acute …
Mr C had a number of health problems. When he fell and hurt himself in hospital, a support worker complained on his behalf that the board provided him with inadequate care. As a result of the fall, Mr C hurt his knee, and had mobility problems. Mr C had found …
SPSO (Scottish Public Se…
Health
Not Upheld
May 2012
201300849 — Greater Glasgow and Clyde NHS Board
Ms C complained that when her late uncle (Mr A) was a patient in hospital, staff failed to provide him with appropriate care for his pressure sore area and that pressure ulcers developed that affected his deteriorating condition. As part of our investigation we took independent advice from our nursing …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013
201203858 — Lanarkshire NHS Board
Mrs C complained about the standard of care and treatment her elderly mother (Mrs A) received in hospital. Mrs C felt that Mrs A was handled roughly by nursing staff and had been left on an incontinence mat with her pyjama bottoms removed and the curtain drawn around her bed …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2013
201301284 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained that her mother (Mrs A) did not received adequate nursing care at a hospital. We noted that the Procurator Fiscal had been involved and so we obtained information from them about their investigation. We found that the Procurator Fiscal had investigated Mrs A's nursing care and reached …
SPSO (Scottish Public Se…
Health
Dec 2013
201201876 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C was unhappy with the medical treatment and nursing care that her late mother (Mrs A) received in hospital over a two-month period. Mrs A was admitted to hospital with a fractured leg and suspected heart attack after a fall at home. Mrs A had an operation shortly after …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2013
201104206 — Lothian NHS Board - Acute Division
Mr and Mrs C's son (Master A) has numerous complex medical conditions and needs constant care. They complained about a number of issues, including the care and treatment provided to their son during a series of admissions to hospital. Their concerns included that their son was not observed frequently enough, …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2014
201306031 — Lanarkshire NHS Board
Mrs C's late aunt (Miss A) had severe chronic obstructive airways disease (a disease in which airflow to the lungs is restricted). Miss A was admitted to Hairmyres Hospital as an emergency with respiratory failure. A doctor reviewed her the next day, and moved her to the medical high dependency …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2014
201304920 — Ayrshire and Arran NHS Board
Mr C complained about the care and treatment provided to his mother-in-law (Mrs A) in Crosshouse Hospital before her death. Mrs A had dementia and had contracted clostridium difficile (C diff - a common healthcare-associated infection), which caused severe diarrhoea. Mr C complained that staff had failed to maintain Mrs …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2015