Outdated Emergency Preparedness Guidance
Outdated, fragmented, and overly long emergency preparedness guidance, lacking emphasis on recovery and identification of vulnerable people.
Source spread
Where this theme appears
This theme appears across 10 independent accountability sources, so the source mix matters as much as the headline total.
14 inquiry recs
34 PFD reports
47 committee recs
1 HSSIB rec
4 PPO recs
3 IOPC recs
5 NAO recs
6 IMB recs
1 Scottish FAI
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(14)
P2-44 — Consolidate and update emergency preparedness guidance
Recommendation: The current guidance on preparing for emergencies is contained in several documents, all of which are unduly long and in some respects out of date. We recommend that the guidance be revised, reduced in length and consolidated in one document …
Gov response: The government accepts this recommendation. We will fully factor it into the outcomes of the resilience review. As a first step, we will publish the revised local responder guidance on ‘Identifying and Supporting Vulnerable People’ …
Accepted
MAI-123 — GM Resilience Forum tri-service plan reviews
Recommendation: The Greater Manchester Resilience Forum should oversee, at least every six months, a regular tri-service review of the Major Incident plans used by Greater Manchester Police, Greater Manchester Fire and Rescue Service and North West Ambulance Service. The purpose of …
Gov response: Accepted in full
Accepted
MAI-99 — Review licensing guidance on event healthcare
Recommendation: The Department for Levelling Up, Housing and Communities should review the guidance given to all licensing authorities on the decisions they make in relation to venues that hold events, and on what level of event healthcare services may be required …
Gov response: Accepted in full
Accepted
MAI-46 — Guidance on Major Incident plan review frequency
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing and the Home Office should issue guidance for all police services on how often operational plans for responding to a Major Incident, including a terrorist incident, …
Gov response: Accepted in full
Accepted
COVID-M5.2 — Pandemic Exercises to Include Emergency Procurement
Recommendation: The UK government and devolved administrations should evaluate the readiness of the structures, systems and processes for the emergency procurement and distribution of healthcare equipment as part of UK-wide pandemic response exercises.
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
COVID-M5.1 — Pandemic Stockpile Composition and Inspection
Recommendation: The UK government and devolved administrations should ensure, within 12 months of the publication of this Report, that the pandemic stockpiles: retain stock that is better aligned with the range and severity of pandemic risks identified in the National Security …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
HIDD-79 — Department of Health to review Circular 71, clarifying Major Incident declaration terms
Recommendation: The Department of Health shall review DHSS Circular 71 in consultation with emergency and medical services to reflect all lessons learned but in particular in relation to procedures for declaring a Major Incident. The Department of Health shall specifically require …
Unknown
COVID-M5.7 — Trade and Industry in the Civil Emergency Strategy
Recommendation: The UK-wide whole-system civil emergency strategy, which the Inquiry has recommended should be developed by the UK government and devolved administrations (see the Inquiry’s Module 1 Report, Recommendation 4), should include specific objectives for international trade and domestic industry during …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
COVID-M5.6 — Blueprints for Critical Care Medical Technology
Recommendation: The UK government and devolved administrations should jointly commission a group of experts to develop blueprints for rapidly scalable critical care medical technology, aligned with the range and severity of pandemic risks identified in the National Security Risk Assessment, within …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
COVID-M5.5 — Emergency Healthcare Equipment Plan
Recommendation: UK regulators, including the Health and Safety Executive, the Health and Safety Executive for Northern Ireland, the Office for Product Safety and Standards and the Medicines and Healthcare products Regulatory Agency, should establish an emergency healthcare equipment cross-regulator plan for …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
COVID-M5.4 — Emergency Healthcare Equipment Regulations
Recommendation: The UK government and devolved administrations should publish simplified regulations for emergency healthcare equipment that are aligned with and cover the range and severity of pandemic risks identified in the National Security Risk Assessment. The simplified regulations should: establish the …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
CR16 — Mass rescue operation plan
Recommendation: HM Coastguard should develop a mass rescue operation plan that includes command and control, co-ordination, external stakeholders, medical and law enforcement roles, and public and external affairs.
Gov response: HMCG refreshed its Mass Rescue Operations Plan in April 2026 (introduced in 2017 and previously amended in 2018 and 2021). It has been updated to ensure continued alignment with IAMSAR and internationally recognised documents such …
Accepted
CR5 — Mass Persons in Water Triage procedure
Recommendation: Those involved in maritime search and rescue should adopt formally the Mass Persons in the Water Triage procedure to govern the operational response to a maritime search and rescue incident when the number of people requiring rescue exceeds the capability …
Gov response: The Multiple Persons in Water Triage Tool developed by HMCG has been adopted by the RNLI and vessels that are contracted by Border Security Command (BSC). Following international consultation and endorsement through the International Mass …
Accepted
COVID-M2.10 — Pandemic Decision-Making Framework
Recommendation: The UK government and devolved administrations should set out in future pandemic preparedness strategies (see the Inquiry’s Module 1 Report, Recommendation 4) how decision-making will work in a future pandemic. This should include provision for COBR to be used as …
Gov response: 3.1. The Welsh Government recognises that an effective response to large-scale emergencies affecting all parts of the UK requires close working among all four nations. We agree that decision-making and coordination processes and structures need …
Accepted
Prevention of Future Deaths reports(34)
Jessica Ashton-Pyatt
Concerns: The response to the patient's admission was uncoordinated and lacked consultant leadership. Additionally, the resuscitation room defibrillator was not charged, and no defibrillation pads were available.
Overdue
Janet Richardson
Concerns: The coroner noted concerns regarding the circumstances in which the deceased fell into the sea during a medical evacuation rescue.
Response (Newmarket Promotions Ltd): • The respondent's clients will ensure that the Coroner's recommendations are forwarded to their suppliers, including Cruise Maritime Services International Ltd (CMV). • The respondent's clients will request that their … (AI summary)
Response (Cruise Maritime Services International Limited): • The respondent stated its existing procedure is to follow the procedures set out by the appropriate rescue service during a rescue operation. • The respondent noted that the Norwegian … (AI summary)
Overdue
Martin Daffydd Barker
Concerns: The coroner identified a lack of national guidance for independent medical service providers on how to alert NHS hospitals about incoming urgent patients. This absence causes confusion and poses a risk to critically ill individuals arriving at hospitals without prior notification or preparation.
Response (North West Ambulance Service NHS Trust): • The North West Ambulance Service (NWAS) confirmed that for organised events, local arrangements are agreed, with NWAS coordinating emergency ambulance response. • NWAS clarified that it does not act … (AI summary)
Overdue
Lucy Moffatt
Concerns: Concerns were raised about window restraints appearing secure but being easily defeated, and the lack of a system for CQC inspectors to be fully aware of Department of Health alerts regarding these devices.
Response (CQC): • The CQC introduced two new indicators in July 2010 to monitor the acknowledgement and completion of safety alerts within its Quality and Risk Profile. • The CQC overhauled its … (AI summary)
Response (Department of Health): • Department of Health officials discussed the report with the Care Quality Commission (CQC) to consider how alerts could reach appropriate teams. • The Care Quality Commission (CQC) stated it … (AI summary)
Responded
Davina Tavener
Concerns: The coroner noted that current aviation safety regulations do not mandate all aircraft to carry essential medical equipment, including defibrillators, airway adjuncts, and suction equipment, which medical experts deem critical for passenger survival during a cardiac arrest.
Response (IAA): • The Irish Aviation Authority (IAA) provided a summary of current automated external defibrillator (AED) carriage by Irish Air Operator Certificate holders. • The IAA Chief Executive wrote to Ryanair … (AI summary)
Response (EASA): • EASA stated it would engage with its Member States to reconsider the situation regarding mandated medical equipment on aircraft through analysis of available data. • EASA confirmed it would … (AI summary)
Response (CAA): • The CAA stated it would keep evidence of such incidents under review and share information and data with EASA colleagues. • The CAA indicated it would further examine the … (AI summary)
Responded
George Hines
Concerns: Insufficient maintenance of emergency pull-cords and smoke detectors in sheltered accommodation, including a disconnected pull-cord, was noted. The smoke detector system also did not alert the Emergency Control Room, and fire instructions were unclear, risking delayed emergency response.
Overdue
James Robertson
Concerns: The coroner noted that carers were not required to log check times accurately, and the system for indicating DNACPR status (stickers/central notes) led to delays in resuscitation. Additionally, a lack of national standards meant the emergency resuscitation pack was missing key equipment.
Overdue
Nathan Charman
Concerns: The winter maintenance policy and decision-making process did not account for extreme local or "microclimatic" road conditions. There has been no formal review or learning sharing following the incident.
Response (Durham County Council): • The Winter Maintenance Operational Plan was amended to align gritting route 28 with the Low Pennines weather forecasting domain. • The Winter Maintenance Operational Plan was amended to confirm … (AI summary)
Responded
Zane Gbangbola
Concerns: The coroner notes that safety guidance documents for internal combustion engine equipment, particularly for use in confined areas, are inadequate and potentially misleading. The use of the HSE logo on these documents risks implying official endorsement, which could exacerbate harm.
Overdue
Joshua Smith
Concerns: The coroner identified deficiencies in the emergency response, including a delay in immediately alerting police, difficulties in identifying the caller's location, and a lack of clear command, control, and coordination, noting that JESIP was not followed.
Response (Maritime Coastguard Agency): • The agency reviewed its systems, issued updated guidance, and modified training packages. • All Coastguard tactical commanders attend JESIP courses, and strategic level commanders attend Multi-Agency 'Gold' courses. • … (AI summary)
Response (Northumberland Fire and Rescue Service): • Northumberland Fire and Rescue Service (NFRS) confirmed and reaffirmed internal procedures for 999 call handling, including dual monitoring and immediate review for missing persons calls. • NFRS reviewed its … (AI summary)
Response (Northumbria Police): • A multi-agency meeting and formal debrief were conducted to discuss the concerns identified in the report. • A specific THRIVE training program for North East Ambulance Service (NEAS) call … (AI summary)
Overdue
John Wilson
Concerns: The coroner identified gaps in Beko's product recall communication, noting that notices sent by standard mail lacked delivery confirmation and follow-up attempts were insufficient, resulting in the deceased being unaware of a hazardous recalled appliance.
Overdue
Mavis Reeves
Concerns: The coroner identified limitations with the analogue Careline system that can impede emergency services access and prevent other residents from making calls when the line is in use. Concerns were also raised about insufficient labelling of keys in the safe, leading to delays for emergency services.
Response (FirstPort Retirement): • Residents were informed of the Careline system's operation during induction, a meeting, and a follow-up letter. • A joint review with Appello Careline was undertaken to ensure correct access … (AI summary)
Responded
Ellie Knowles
Concerns: The coroner noted a license for holding dance music events at Hoults Yard remains active, despite assurances no further similar events would occur. A robust internal protocol is recommended, requiring consultation with police and council licensing officers for any future events.
Overdue
Christopher McGuffie
Concerns: The coroner noted the absence of immediate and effective alert systems at railway stations for persons on the line, as well as alternative detection methods to trigger appropriate responses.
Response (Arriva): • Arriva Rail North provides suicide intervention training to all frontline staff and is revising induction training to include a module in this area. • The company is installing Ticket … (AI summary)
Responded
Matthew Lewis
Concerns: The coroner noted confusion among emergency responders regarding call handler instructions, which appeared inconsistent with the primary duty to preserve life. Clearer guidance and training for call handlers are needed to ensure effective responses in hanging incidents.
Response (South Wales Police): • South Wales Police confirmed it has a procedure for new and inexperienced call handlers, involving monitoring by a trainer or experienced operator. • South Wales Police developed a new … (AI summary)
Response (College of Policing): • The College of Policing stated it would amend learning standards for contact management staff to reflect that the preservation of life is paramount and that suitable instructions should be … (AI summary)
Responded
Saeid Hedayat
Concerns: West Sussex County Council's drain clearance risk assessments did not consider zone 1 blockages, lacked regular review, and were not updated despite increased storm severity or public reports. There were also no warning signs for regularly flooding areas.
Response (West Sussex County Council): • West Sussex County Council reviewed its gully cleansing data in 2019 and implemented an optimised programme. • The council adopted a new approach to record 'Zone blockages' to enhance … (AI summary)
Responded
Thomas Reilly
Concerns: The lack of a formal, structured intervention system at suicide hotspots, relying on ad-hoc approaches, raises concerns about consistent prevention of self-harm.
Overdue
Flora Shen
Concerns: The coroner noted the multi-step process for passengers to alert staff and for staff to activate the emergency brake. There is a reliance on members of the public to identify hazards on the track and activate alarms, as the central CCTV system cannot monitor all stations simultaneously.
Response (Office of Rail and Road): • The Office of Rail and Road (ORR) confirmed that DLR and KAD's risk assessments for persons on the track were suitable and sufficient. • The ORR confirmed that DLR … (AI summary)
Response (TFL): • Signage on platform alarms will be enhanced, with a programme to be rolled out on a risk-basis by July 2021. • Research into hazard and obstacle detection solutions will … (AI summary)
Overdue
Gillian Davey
Concerns: The coroner noted the absence of professional lifeguard cover on Cornish beaches, including on Bank Holiday Monday when incidents occurred, and highlighted a lack of a public plan for reinstating these services.
Response (Maritime and Coastguard Agency): • The Maritime and Coastguard Agency (MCA) promotes safety messages for the general public regarding beach safety. • The MCA produced guidance on Managing Beach Safety for landowners. • The … (AI summary)
Response (RNLI): • The RNLI confirmed it had deployed lifeguard patrols on 18 beaches, with 8 located in Cornwall. • The RNLI stated it was revising its plans to explore additional beaches … (AI summary)
Response (Maritime and Coastguard Agency): • The Maritime and Coastguard Agency updated a Beach Safety Guide and developed additional guidance on beach safety during a pandemic. • The agency intends to publish an independent review … (AI summary)
Responded
Michael Pender
Concerns: The coroner noted the absence of professional lifeguard cover on Cornish beaches, particularly on a Bank Holiday Monday, and the lack of a clear public plan for its reinstatement. This situation increases the risk of further loss of life.
Response (RNLI): • RNLI lifeguards were deployed on 18 beaches, including 8 in Cornwall, in the preceding weekend. • The organisation is revising its plans and collaborating with 55 landowners and local … (AI summary)
Response (Maritime and Coastguard Agency): • The Maritime and Coastguard Agency stated it has no remit for beach safety or the provision of lifeguarding. • The agency promotes safety messages and campaigns for the public … (AI summary)
Response (Maritime and Coastguard Agency): • The Maritime and Coastguard Agency (MCA) updated a Beach Safety Guide and developed additional guidance for beach owners. • The MCA intends to publish an independent review of beach … (AI summary)
Responded
Jan Klempar
Concerns: The coroner notes reduced lifeguard cover on Cornish beaches compared to 2019 levels and identifies a lack of a clear, publicised plan detailing lifeguard provision and mitigation strategies for reduced service.
Response (Maritime and Coastguard Agency): • The Maritime and Coastguard Agency (MCA) collaborated with RNLI partners on a joint publicity campaign to encourage public responsibility and emergency contact. • HM Coastguard worked with Surf Life … (AI summary)
Response (RNLI): • The RNLI provided lifeguard cover on 177 beaches in 2020, including 47 in Cornwall, which represented 80% of the beaches normally lifeguarded in the region. • Information detailing lifeguard … (AI summary)
Responded
Anthony Williamson
Concerns: The coroner raised concerns regarding the adequacy of coastguard and lifeguard cover around the Cornish coastline. This included enquiring about potential reductions due to the pandemic, how any shortfalls are mitigated, and if public plans are published.
Response (Maritime and Coastguard Agency): • HM Coastguard maintained emergency provision for search and rescue throughout the national lockdown. • HM Coastguard deployed additional vehicle patrols to high-risk areas for extra surveillance during the summer … (AI summary)
Response (the RNLI): • The RNLI implemented various preventive measures for unguarded beaches, including roving patrols, bespoke signage, and providing community access to rescue equipment. • The RNLI collaborated with Cornwall County Council … (AI summary)
Responded
Andrew Westlake
Concerns: The report identifies insufficient training for airline and ground staff regarding the vulnerability of lone passengers disembarked overseas, and a lack of procedures for safeguarding such individuals.
Response (JET): • Jet2.com updated its Ground Handling Manual to include acute mental health issues as a hidden disability requiring special assistance. • Jet2.com revised its Denied Boarding procedure to include consideration … (AI summary)
Response (CAA): • The Civil Aviation Authority (CAA) contacted Jet2.com to discuss the airline's intended response to the concerns and reviewed Jet2.com's updated Ground Operations Policy. • The CAA Executive will receive … (AI summary)
Responded
Nicholas Winterton
Concerns: The coroner notes that Public Health England's nationally recognised risk for Mycobacterium Chimaera infection is inaccurate, based on outdated 2017 data and underreporting, impacting informed consent and timely diagnosis. An immediate review and update of this statistical data is required.
Response (UK Health Security Agency): • Public Health England (PHE) undertook an updated risk assessment in November 2019, which was submitted for publication but delayed, and will further update and publish risk estimates by September … (AI summary)
Overdue
Zainab Hashim and Tafaoul Abdulkarim
Concerns: The coroner noted residents were unaware of the 'Stay Put' fire policy in council-owned flats, and Stoke-on-Trent City Council had not changed its communication methods for this policy. This lack of resident awareness was identified as a risk of future deaths.
Response (Stoke-on-Trent City Council): • The Council communicates its Stay Put Policy through translated Fire Safety Notices provided to residents, displayed in communal areas, and verbally reinforced during annual Tenancy Audit Visits. • Housing … (AI summary)
Responded
Vinnie Dodds
Concerns: The coroner noted the absence of national guidance for managing large babies without maternal diabetes. Concerns were raised regarding insufficient information provided to mothers about the risk of death from shoulder dystocia, and its omission from the RCOG patient information leaflet.
Response (Dept of Health and Social Care): • The Department noted that NICE Clinical Guideline NG121 provides recommendations for discussing large for gestational age babies in labour. • The Department noted that existing GMC guidance on informed … (AI summary)
Responded
Rita Britten
Concerns: The coroner identified a lack of clear national emergency guidelines for managing choking incidents in overweight or obese individuals where conventional abdominal thrusts are ineffective. The report suggests reviewing alternative techniques, such as inversion, and specialist equipment for these circumstances.
Response (NHS England): • NHS England stated that the Resuscitation Council UK had addressed the concerns raised in the report. • NHS England brought the matters of concern to the attention of its … (AI summary)
Response (Resuscitation Council): • The Resuscitation Council UK stated it would include a frequently asked question on its national website to highlight its position on managing choking in individuals where conventional abdominal thrusts … (AI summary)
Responded
Levi Alleyne
Concerns: The coroner identified insufficient national standard operating procedures for ambulance services to contact Distribution Network Operators (DNOs) regarding electrical hazards. This can delay life-saving treatment and pose safety risks for responders due to multiple DNOs and the absence of a single national emergency number.
Response (Energy Networks Association): • ENA asked member companies to confirm arrangements for annual communication of network boundaries with local emergency services by 31st January 2023. • ENA stated it would open dialogue with … (AI summary)
Response (NHS England): • NHS Pathways stated its remit does not extend to preparing or overseeing local or national standard operating procedures or providing national oversight of 111 or 999 operations. • NHS … (AI summary)
Response (AACE): • Updated Standard Operating Procedures (SOPs) from South Central Ambulance Service NHS Trust, which include maps and contact details for electricity Distribution Network Operators, have been shared with all NHS … (AI summary)
Response (Health and Safety Executive): • The Health and Safety Executive shared the report with the Care Quality Commission and Healthcare Inspectorate Wales for their consideration. • The Association of Ambulance Chief Executives advised that … (AI summary)
Overdue
Christine McDonald
Concerns: The report identifies concerns regarding the non-use of emergency response codes, which left first responders unprepared for the situation they attended. It also notes the difficulty in training staff for unexpected emergencies and the potential for improved control room measures.
Response (HM Prison and Probation Service): • A national video demonstrating responses to medical emergencies and appropriate use of emergency codes was launched in January 2024, made available to all HMPPS staff, and delivered to new … (AI summary)
Overdue
Samsam Ateye
Concerns: The coroner raised concerns regarding the policy for Covid-19 testing before cardiac surgery, specifically valve replacement procedures.
Response (NHS England): • NHS England published advice on COVID-19 testing for elective care pre-admission patients in early 2022, which advises a risk-based approach. • This national advice aligns with guidance published by … (AI summary)
Responded
Champagauri and Dipak Bhatt
Concerns: The coroner raises concerns about fire risks due to moisture ingress into condensate pumps, and highlights gaps in data sharing, analysis, and manufacturing standards related to white goods fires.
Response (Hotpoint UK Appliances Ltd): • Hotpoint noted that the PRISM methodology was not developed for pre-market product design assessment, citing guidance from the Office for Product Safety and Standards. • Hotpoint confirmed its active … (AI summary)
Response (Association of Manufacturers of Domestic Appliances): • AMDEA stated it would collaborate with industry stakeholders to enhance product safety. • AMDEA confirmed it would continue to share insights at national and international standards development committee meetings. … (AI summary)
Response (BSI Group): • BSI's CPL/61 committee convened a meeting on 21 January 2025 to discuss the report. • The committee requested specific information, including expert reports and appliance details, to inform its … (AI summary)
Response (North Yorkshire County Council): • Hotpoint UK Appliances Ltd conducted forced failure testing of components and a risk assessment, which indicated no need for a recall or component improvements. • North Yorkshire Council's trading … (AI summary)
Response (National Fire Chiefs Council): • The National Fire Chiefs Council (NFCC) stated that receiving information from manufacturers on specific component parts is not within its current remit. • The NFCC supports the national single … (AI summary)
Response (Office for Product and Safety Standards): • OPSS established a process for Fire and Rescue Services to report product-related fires and published guidance to assist reporting. • OPSS will work with the British Standards Institution (BSI) … (AI summary)
Response (Home Office): • Suitably qualified Fire Investigation Officers attend fatal fires and undertake Tier 2 investigations. • Fire and Rescue Services conduct fatal fire reviews, producing reports that include learning. • Learning … (AI summary)
Response (Chartered Trading Standards Institute): • CTSI stated it could work with the Office for Product Safety and Standards (OPSS) and local authority Trading Standards Officers to ensure effective communication of safety issues and recalls. (AI summary)
Responded
Luke Albiston O’Donnell
Concerns: The coroner noted a lack of public appreciation for the life-threatening risks associated with storing lithium-ion batteries from e-bikes in domestic properties, identifying insufficient communication and media coverage on these dangers.
Response (OPSS): • The Government launched the 'Buy Safe, Be Safe' campaign in October 2024 to raise awareness of risks associated with unsafe e-bikes and their batteries. • OPSS published independent research … (AI summary)
Response (NFCC): • The National Fire Chiefs Council operates the 'Charge Safe' campaign, providing public advice on charging e-bikes and e-scooters. • The NFCC is undertaking further research to understand lithium-ion battery … (AI summary)
Responded
Jean Langan
Concerns: The coroner identified a need for a real-time database of hospital helicopter landing sites and contact details for site managers to ensure safe helicopter landings.
Response (Department for Transport): • The Department for Transport (DfT) is considering whether to legislate to ensure safety at all hospital helicopter landing sites (HHLSs). • The DfT has begun developing options for a … (AI summary)
Response (Department of Health and Social Care): • A named accountable manager for each Hospital Helicopter Landing Site (HHLS) has been identified and supplied for all Trusts as of 31 January 2025. • The Department of Health … (AI summary)
Responded
Stuart Gilchrist
Concerns: The coroner noted that restaurants and food establishments may be unaware of devices available to assist in choking incidents and questioned who is responsible for advising them of such items.
Response (East Riding Council): • The Local Authority stated it does not have powers to specify equipment for first aid kits or publish guidance on their contents. • The Local Authority indicated it would … (AI summary)
Response (Health and Safety Executive): • The Health and Safety Executive stated that its regulations for workplace first aid provision do not apply to non-employees such as restaurant customers. • The Health and Safety Executive … (AI summary)
Overdue
Select committee recommendations(47)
#22 —
Recommendation: The evidence we have received, and a comparison with our allies, leads us to conclude that the UK’s economic security regime is no longer fit for the future. A whole-of-society approach must become the organising principle of Britain’s economic security. …
#6 —
Recommendation: The Government’s reticence to use the Civil Contingencies Act in response to a genuine national emergency calls into question how fit for purpose that legislation is.
Response attribution not verified
#118 — Consider physical cash value in emergency preparedness and severe payment system outages
Recommendation: In discharging its responsibility for national security and resilience, HM Treasury must consider the value of physical cash in emergency preparedness. This may include recommending that cash is held by individuals in case of emergency, and considering what role cash …
Response attribution not verified
#19 — UK preparedness for acute AMR risks is strong initially, but scaling up remains challenging.
Recommendation: We also asked DHSC about the UK’s preparedness for addressing the chronic risk of AMR and the possibility of it becoming an acute risk. DHSC told us that the UK has a strong base which would make the initial response …
Response attribution not verified
#18 — AMR is a chronic risk with potential acute threats, hindering sustained government focus.
Recommendation: The government categorises AMR as one of 26 ‘chronic’ risks facing the UK, which means that it poses a long-term, continuous challenge to the UK, as opposed to an ‘acute’ risk which is an immediate threat which may require an …
Response attribution not verified
#22 — Government's hate crime action plan remains expired, missing strategic opportunity.
Recommendation: It is disappointing that the Government has not updated the hate crime action plan, which expired in 2020. The lack of an action plan is a missed opportunity to provide a coherent, cross-departmental strategy on tackling intersectional hate crime. (Conclusion, …
Response attribution not verified
#4 — Police forces were unprepared for high levels of violence during last summer's disorder.
Recommendation: The levels of violence seen across the country last summer were the worst since 2011. Police officers worked tirelessly to respond to the disorder and it was only through their efforts that more serious injury and property damage was prevented. …
Response attribution not verified
#46 —
Recommendation: Building new towns, connecting them to utilities and then populating them—but without ensuring that they have a sustainable supply of water and energy—would constitute a risk to national resilience. This would be irresponsible. Mr Colville alerted the Committee to the …
#42 —
Recommendation: For decades, successive governments, water companies and regulators have failed to work together to anticipate effectively future demand for water. 65 Meanwhile, the water industry has not factored major future demands (such as new towns or data centres) into its …
#36 —
Recommendation: New towns will require a constant supply of water, energy and digital connectivity for their new inhabitants. Unfortunately (and deeply regrettably) this presents a challenge for the Government, because of decades of poor planning and a lack of effective preparation …
#7 —
Recommendation: We need to re-learn some of the Cold War lessons around deterrence and escalation management and apply them to a new context.
Response attribution not verified
#15 —
Recommendation: The Government should ensure that the UK Resilience Academy is reviewing preparedness plans specifically in relation to the estimated impacts of Reasonable Worst Case Scenarios as set out in the National Risk Register, including the possibility of direct threat to …
Response attribution not verified
#17 —
Recommendation: The Government’s published draft legislation for implementing future local lockdowns (referred to in Chapter 2 of this report) should mean that it is easier to publish all information immediately when implementing new local lockdowns or relaxing local lockdowns slowly. However, …
Response attribution not verified
#78 —
Recommendation: As a result, decisions on lockdowns and social distancing during the early weeks of the pandemic—and the advice that led to them—rank as one of the most important public health failures the United Kingdom has ever experienced. This happened despite …
Response attribution not verified
#41 —
Recommendation: There is minimal spare capacity in the UK’s water supply, making it vulnerable to droughts and increases in demand. 63 Stuart Colville, Deputy Chief Executive of WaterUK, told the Committee that “in some parts of the country, headroom—spare water—is down …
#29 —
Recommendation: The Committee heard concerns about a lack of national strategic oversight for long-term materials planning. 45 We were told that the UK lacks a national understanding of the vulnerabilities in its supply chains, despite robust understanding at a project level. …
#5 —
Recommendation: The Government’s desire to find alternatives, such as bespoke primary legislation, to using the emergency provisions of the Civil Contingency Act 2004 is understandable. Bespoke primary legislation has the advantage of going through the stages of Parliamentary scrutiny. However, the …
Response attribution not verified
#6 —
Recommendation: We are not convinced that the Department is sufficiently prepared to safeguard the status of individuals while also implementing a new immigration system and managing its response to the COVID-19 pandemic. The Department faces several challenges in the immediate future. …
Response attribution not verified
#5 —
Recommendation: The Department is unprepared for the challenges the UK’s exit from the EU presents to its immigration enforcement operations. The Department relies on cooperation with EU partners to support its international operations, including the return of foreign national offenders and …
Response attribution not verified
#3 —
Recommendation: The evidence we received covering the general role of the Office of the Secretary of State for Scotland has been helpful. We look forward to hearing a response to the recommendation in the interim report about the specific role of …
Response attribution not verified
#2 —
Recommendation: The Cabinet Office and Government Office for Science should update SAGE guidance to set out the role that SAGE will play in advising the Government’s long-term management of emergency scenarios. (Paragraph 34) Activation and operation of SAGE
Response attribution not verified
#2 —
Recommendation: Civilian agencies will inevitably require assistance in a crisis of this scale and there should be no stigma in seeking help from the Armed Forces. However, it is clear that preparations for a non-man-made threat such as an infectious disease …
Response attribution not verified
#2 —
Recommendation: Previous exercises to test the national response capability, namely Exercises Cygnus and Winter Willow, did not squarely address a disease with the characteristics of covid-19. Nevertheless, some useful lessons were learned and applied, such as the drafting of legislative measures …
Response attribution not verified
#77 —
Recommendation: The initial UK policy was to take a gradual and incremental approach to introducing non-pharmaceutical interventions. A comprehensive lockdown was not ordered until 23 March 2020—two months after SAGE first met to consider the national response to covid- 19.99 This …
Response attribution not verified
#2 —
Recommendation: Previous exercises to test the national response capability, namely Exercises Cygnus and Winter Willow, did not squarely address a disease with the characteristics of covid-19. Nevertheless, some useful lessons were learned and applied, such as the drafting of legislative measures …
Response attribution not verified
#77 —
Recommendation: The initial UK policy was to take a gradual and incremental approach to introducing non-pharmaceutical interventions. A comprehensive lockdown was not ordered until 23 March 2020—two months after SAGE first met to consider the national response to covid- 19.99 This …
Response attribution not verified
#5 —
Recommendation: Government would have been better prepared for COVID-19 if it had applied learning from previous incidents and exercises. Government was unprepared for a pandemic with widespread asymptomatic transmission, but this was not unprecedented. The early spread of HIV, too, was …
Response attribution not verified
#25 —
Recommendation: Given the importance of refining interventions to mitigate both impacts on public health and economic recovery, a review of social distancing measures came quite late. While the scientific approach quite rightly waits for the evidence before making a definitive recommendation, …
Response attribution not verified
#1 —
Recommendation: The coronavirus pandemic marks the most significant test of the UK’s emergency advisory and decision-making structures in living memory. As such, it is important that lessons are drawn throughout and applied so that the Government and future Governments may be …
Response attribution not verified
#18 —
Recommendation: In March 2020, officials from NHS England & NHS Improvement publicly assured the Health and Social Care Select Committee that these stockpiles meant the country was well placed to manage the COVID19 pandemic. However, the NAO report found that the …
Response attribution not verified
#17 —
Recommendation: Government had a Pandemic Influenza Preparedness Programme and a stockpile of PPE for managing an influenza pandemic, but not a coronavirus pandemic (such as COVID-19). Public Health England told us this was because the national risk register identified an influenza …
Response attribution not verified
#2 —
Recommendation: While government had plans and a stockpile of PPE, this proved inadequate for the COVID-19 pandemic. The Department had a strategy for managing an influenza pandemic, which included a stockpile of PPE owned and managed by Public Health England. In …
Response attribution not verified
#1 —
Recommendation: From the evidence it is clear that there was a disconnect between the assessment of the threat of an infectious disease pandemic (flu or otherwise) and the preparations for such an event occurring. Subsequent government actions (such as the re-drawing …
Response attribution not verified
#1 —
Recommendation: The UK has established procedures and structures to prepare for the nation’s major future risks, including a National Risk Register, the Civil Contingencies Secretariat and the Scientific Advisory Group for Emergencies (SAGE). However, the anticipated future risk of pandemic disease …
Response attribution not verified
#80 —
Recommendation: Non-pharmaceutical interventions such as lockdowns, and the testing and isolation of covid cases and their contacts, are tools of temporary application. Once they are lifted, there is nothing to stop transmission resuming. When Sir Patrick Vallance said at a Government …
Response attribution not verified
#75 —
Recommendation: Much of the impact of covid-19 during the first wave was determined by decisions made during the early weeks of the pandemic, between January and late March 2020. The seriousness of the threat to the UK was recognised in January …
Response attribution not verified
#69 —
Recommendation: The Armed Forces should have a more central and standing role in preparing for and responding to emergencies like pandemics, given the depth of capability and experience they have in planning, logistics and rapid mobilisation. The Civil Contingencies Secretariat should …
Response attribution not verified
#1 —
Recommendation: The UK has established procedures and structures to prepare for the nation’s major future risks, including a National Risk Register, the Civil Contingencies Secretariat and the Scientific Advisory Group for Emergencies (SAGE). However, the anticipated future risk of pandemic disease …
Response attribution not verified
#75 —
Recommendation: Much of the impact of covid-19 during the first wave was determined by decisions made during the early weeks of the pandemic, between January and late March 2020. The seriousness of the threat to the UK was recognised in January …
Response attribution not verified
#69 —
Recommendation: The Armed Forces should have a more central and standing role in preparing for and responding to emergencies like pandemics, given the depth of capability and experience they have in planning, logistics and rapid mobilisation. The Civil Contingencies Secretariat should …
Response attribution not verified
#29 —
Recommendation: We found in our report on Government preparedness for the COVID-19 pandemic: lessons for government on risk that government would have been better prepared for COVID-19 if it had applied learning from previous incidents and exercises.52 The NAO reported that, …
Response attribution not verified
#24 —
Recommendation: Throughout the pandemic, the UK has relied on its own bespoke system of science advice and guidance on non-pharmaceutical interventions, while at the same time global-level guidance has been issued regularly by the World Health Organisation (WHO). There have also …
Response attribution not verified
#28 —
Recommendation: The NAO reported that the circumstances in which government had to implement the traffic light system had often been a crisis response requiring government to move at pace.49 The Cabinet Office explained that the system was a response to the …
Response attribution not verified
#27 —
Recommendation: We acknowledge that a large part of the success to date into the development of covid-19 vaccines and therapeutics can be credited to lessons learned from previous outbreaks and efforts made to prepare for future crises. As further promising vaccine …
Response attribution not verified
#10 —
Recommendation: We welcome the assurances that public health is a priority for the COP26 Unit, while acknowledging the challenges presented by continuing uncertainties. We recommend that the UK Government engages on this issue constructively with the Scottish Government. The Government should …
Response attribution not verified
#7 — Serious threat to UK warfighting ability due to Airborne Early Warning capability gap
Recommendation: With only a limited number of (comparatively vulnerable) fixed and mobile land- based radars on UK soil, all of which would be primary targets for our opponents were the current Ukraine conflict to escalate, the capability gap in Airborne Early …
Response attribution not verified
#28 — National resilience standards for LRFs are voluntary, with many outdated community risk registers
Recommendation: Local organisations have a critical role in responding to emergencies and building resilience.50 Emergency responders in a local area convene in local resilience forums (LRFs) and the Cabinet Office published a set of national resilience standards for LRFs in 2020. …
Response attribution not verified
HSSIB safety recommendations(1)
PPO death in custody recommendations(4)
The Governor
The Governor should ensure that all prison staff are made aware of and understand PSI 03/2013 on medical emergency codes so that staff accurately and appropriately communicate the nature of a prisoner’s medical condition.
The Director
The Director should ensure that all staff understand their responsibilities in a medical emergency, including that they radio the appropriate medical emergency code without delay.
The Governor
The Governor should ensure that an ambulance is called promptly if a qualified clinical professional says that one is required.
The Head of Healthcare
The Head of Healthcare should ensure that all emergency response staff attend medical emergency codes immediately.
IOPC learning recommendations(3)
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: The leads on emergency services multi-agency working at the National Police Chiefs Council (NPCC), National Fire Chiefs Council (NFCC) and the Association of Ambulance Chief Executives (AACE) monitor services’ compliance with the JOL action note. On …
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: Joint Emergency Service Interoperability Principles (JESIP) issues a ‘Joint Organisational Learning’ (JOL) action note to all emergency services, requiring them to: - include the NPAS guidance in their training for call handlers; and - ensure that …
National recommendations and recommendations made to the Metropolitan Police Service and West …
The IOPC recommends that: The National Police Air Service (NPAS) develops guidance for emergency services call handlers on NPAS helicopter capabilities, making it clear that NPAS helicopters do not have a rescue capability. This guidance should also: - state that …
NAO audit recommendations(5)
The government’s approach to test and trace in England – interim report
b) plan against a range of plausible outcomes to ensure it has flexibility to respond to predictable and unexpected spikes in testing demand. Problems emerged when schools and universities reopened in September, despite a predictable spike in demand. NHST&T also …
Partially accepted
Resilience to animal disease
g ensure their disease outbreak plans are comprehensive and up-to-date, including updating disease-specific plans where required, ensuring plans cover responding to concurrent large exotic disease outbreaks and a scenario where capacity is insufficient, and developing a contingency plan for an …
Accepted
Managing cross-border travel during the COVID-19 pandemic
b) Departments should establish a clear system-level risk management framework to support government decision-making. The framework needs to be responsive to capture the dynamic and complex circumstances of the pandemic; informed by up-to-date data against relevant performance metrics, captured and …
Accepted
Managing cross-border travel during the COVID-19 pandemic
a) Departments should establish who is responsible for capturing and managing the risks for an overall system-based approach to COVID-19 or similar travel measures. Working together, departments should clarify the government?s risk appetite as a basis for any future cross-border …
Accepted
Delivery of employment support schemes in response to the COVID-19 pandemic
k) HM Treasury should ensure it develops robust plans for responding to economic shocks linked to health, environmental or other crises. Plans should be stress-tested to identify improvements and continually refined
Accepted
IMB individual recommendations(6)
Ford (2020)
For the second year running the Board comments on your service’s apparent lack of understanding of Category D open prisons. The Prisons National Framework response to COVID-19 including the coloured Levels/Stages diagram and supporting text failed to mention ROTL, even at Levels 1 or 2 where it might be expected. The Board understands that the number one priority was the …
HMPPS
In Progress
Aylesbury (2020)
Move out of COVID-19 lockdown protocols as swiftly and smoothly as possible, following guidelines as necessary.
Governor / Director
In Progress
Send (2021)
The Board urges the Ministry of Justice to learn lessons from the last 12 months to develop a strategy for a future pandemic which ensures the humane treatment of prisoners (3.2).
Ministry of Justice
In Progress
Heathrow and City airports Short Term Holding Facilities (2021)
Border Force should ensure that all its staff are aware that the terminal evacuation protocol requires that C&C are informed without delay to enable them to evacuate the holding rooms.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
Implemented the partially accepted recommendation that a new holding room be set up in Terminal 2 at Edinburgh Airport.
Other
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
We repeat our previous recommendation that Prestwick STHF, which remains out of use, should be brought up to basic requirements.
Other
Independent reviews(6)
Pitt Floods Review — Rec 80
All central government guidance should be updated to reflect the new arrangements for recovery and Local Resilience Forums should plan, train and exercise on this basis.
Other
Pitt Floods Review — Rec 56
The Government should issue clear guidance on expected levels of Category 2 responders’ engagement in planning, exercising and response and consider the case for strengthening enforcement arrangements.
Other
Pitt Floods Review — Rec 40
Defra should amend emergency regulations to increase the minimum amount of water to be provided in an emergency, in order to reflect reasonable needs during a longer-term loss of mains supply.
Other
Pitt Floods Review — Rec 32
The insurance industry should develop and implement industry guidance for flooding events, covering reasonable expectations of the performance of insurers and reasonable actions by customers.
Other
Pitt Floods Review — Rec 30
The Government should review and update the guidance Insurance for all: A good practice guide for providers of social housing and disseminate it effectively to support the creation of insurance with rent schemes for low income households.
Other
Pitt Floods Review — Rec 26
The Government should develop a single set of guidance for local authorities and the public on the use and usefulness of sandbags and other alternatives, rather than leaving the matter wholly to local discretion.
Other