Outdated Operational Guidance
Lack of real-time access for operational staff to up-to-date and succinct guidance, leading to potential inconsistencies or errors in enforcement.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
126 inquiry recs
221 PFD reports
84 committee recs
16 HSSIB recs
126 CQC actions
9 ICIBI recs
10 PPO recs
76 IOPC recs
1 NAO rec
2 IMB recs
1 patient safety alert
18 Scottish FAIs
2 detention investigation recs
92 DHR recs
1 PHSO decision
2 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(126)— showing 50 strongest matches
13 — AWS is vital to the continued running of the train
Recommendation: AWS is to be regarded as vital to the continued running of the train (para 15.11).
Unknown
12 — Designate train-borne safety equipment as vital or not
Recommendation: All train-borne safety equipment should be clearly designated as to whether or not it is vital to the continued running of the train (para 15.11).
Unknown
11 — Avoid using several documents for one operational issue
Recommendation: The use of more than one document (whether Rules, Group Standards or otherwise) to cover a single operational issue should be avoided, save where proper reasons exist for use of multiple sources (para 15.9).
Unknown
10 — Rules and Group Standards clear and unambiguous
Recommendation: Railtrack must ensure that Rules and Group Standards applicable to operators, including drivers, are clear and unambiguous. In particular, Railtrack should urgently complete the review of operating Rules to ensure they are workable in the privatised, fragmented industry (para 16.6).
Unknown
9 — Review of drivers' working hours
Recommendation: Current Rules governing drivers’ permitted daily and weekly working hours should be reviewed in the light of current research into human behaviour (para 5.9).
Unknown
5 — Testing of driver competence and knowledge of the Rules
Recommendation: Testing of driver competence and knowledge of Rules should be extended to cover application of the Rules to practical situations, including all abnormal driving situations permitted by the Rules (para 16.4).
Unknown
4 — Driver training in abnormal situations
Recommendation: Driver training should include driving in abnormal situations permitted by the Rules and specifically driving with AWS isolated to the extent so permitted, including the use of simulators (para 16.4).
Unknown
29 — New edition of national guidelines
Recommendation: A new edition of national guidelines for Scotland should be prepared embodying extracts from the relevant legislation (15.58-59) set in the context of a clear statement of basic principles (15.60).
Unknown
91 — Withdrawal of areas of operation section
Recommendation: Sec 3 of the code for the assessment of standby vessels (areas of operation) should be withdrawn (para 20.39).
Unknown
90 — Revocation of Reg 10
Recommendation: Reg 10 of the Emergency Procedures Regulations should be revoked (para 20.39).
Unknown
53 — Withdrawal of fire protection discussion document
Recommendation: The DEn discussion document on Fire and Explosion Protection should be withdrawn (para 19.102).
Unknown
21 — Review PLA byelaw 19
Recommendation: We recommend that the PLA give further consideration to byelaw 19 in the context of the collision regulations, especially rules 13 and 17, and consider whether it is appropriate to spell out the obligations of a vessel affected by byelaw …
Unknown
67 — Defining the personal officer role
Recommendation: The role of the personal officer should be clearly defined in each establishment’s personal officer scheme. The Prison Service should publish a model scheme, which should be regarded as having been adopted by every establishment which does not produce one …
Unknown
52 — Guidance for duty governors on risk assessment
Recommendation: The instructions for completing the form should give duty governors guidance on how to exercise the options available to them when dealing with prisoners who are both at risk of self-harm and a risk to their cellmate.
Unknown
50 — Prisoner escort record handbook and completion
Recommendation: The handbook giving guidance on how to complete the prisoner escort record should be revised to make it clear that it is not merely of use while a prisoner is in transit, but it is also intended to inform the …
Unknown
47 — Model procedure for external report comments
Recommendation: The Prison Service should publish a model procedure dealing with how establishments should bring Prison Service Orders and other instructions, whether national or local, which affect the management of prisoners to the attention of staff. The model procedure should be …
Unknown
RONA-45 — Bring Code of Practice 3 Chapter V Loading up to date
Recommendation: Code of Practice 3: Chapter V: Loading, must, as a matter of urgency, be brought up to date and should take account of recent research into the frequency and duration of high winds particularly on high buildings (paragraph 214).
Unknown
28 — Revise Prison Service safeguarding guidance
Recommendation: The Chair and Panel note that Prison Service Instruction (PSI) 08/2012, which sets out the mandatory actions for YOIs and STCs for 'maintaining a safe and secure environment', has expired. The Chair and Panel recommend that the Ministry of Justice …
No response yet
BAHA-19 — JDP 1-10 Redraft Clarity
Recommendation: In the current redrafting of JDP 1-10 and in future subordinate doctrine and instructions regarding CPERS: (1) plain English, simplicity of structure and brevity should be given greater priority while allowing for the target audience and complexity of the subject …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
COVID-M2.3 — UK-wide Expert Register
Recommendation: The Government Office for Science (GO-Science) should develop and maintain a register of experts across the four nations of the UK who would be willing to participate in scientific advisory groups, covering a broad range of potential civil emergencies. The …
Gov response: GO-Science already maintains an expert register for SAGE and is committed to refreshing the register; improving selection processes to broaden participation across disciplines, institutions and backgrounds; and increasing our engagement with experts outside of emergencies. …
Accepted
COVID-M1.10 — Independent Statutory Resilience Body
Recommendation: The UK government should, in consultation with the devolved administrations, create a statutory independent body for whole-system civil emergency preparedness and resilience. The new body should be given responsibility for: providing independent, strategic advice to the UK government and devolved …
Gov response: Since the pandemic, significant strategic and material changes have been made to the way in which the UK and devolved governments handle crises. Considerable progress has been made against the longer-term programme to build a …
Response Unclear
COVID-M1.7 — Publish Exercise Reports and Lessons
Recommendation: For all civil emergency exercises, the governments of the UK, Scotland, Wales and Northern Ireland should each (unless there are reasons of national security for not doing so): publish an exercise report summarising the findings, lessons and recommendations, within three …
Gov response: The government agrees that, given the UK-wide cross-cutting implications, the UK government should publish findings and lessons from all Tier 1 civil emergency exercises (except where there are justifiable reasons not to do so, such …
Accepted
COVID-M1.6 — Triennial Pandemic Exercises
Recommendation: The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak …
Gov response: The government agrees that regularly programmed exercises should test pandemic preparedness. A ministerial, national level (Tier 1) exercise has been programmed for 2025 to test the response to a major pandemic. In addition, smaller scale …
Accepted
COVID-M1.3 — Improved Risk Assessment Approach
Recommendation: The UK government and devolved administrations should work together on developing a new approach to risk assessment that moves away from a reliance on single reasonable worst-case scenarios towards an approach that: assesses a wider range of scenarios representative of …
Gov response: The government agrees with the need to continually improve its approach to risk assessment as the basis for the entire system of preparedness and resilience. The government’s principal framework for risk assessment is the National …
Accepted
POH-19 — Publish restorative justice programme by 31 October 2025
Recommendation: By 31 October 2025, the Department, Fujitsu and the Post Office shall publish, either separately or together, a report outlining any agreed programme of restorative justice and/or any actions taken by that date to produce such a programme. For the …
Gov response: DBT, the Post Office and Fujitsu have jointly embarked on a restorative justice project for postmasters, facilitated by the Restorative Justice Council. All 3 parties are committed to the programme being postmaster-led. The first phase …
Accepted
POH-18 — Devise redress process for affected family members
Recommendation: The Department shall devise a process for providing financial redress to close family members of those most adversely affected by Horizon. Such family members shall qualify for such redress only if they themselves, have suffered serious adverse consequences by reason …
Gov response: Some family members of postmasters suffered gravely because of the Horizon scandal. As set out in the Minister for Postal Affairs’ statement to the House of Commons on 8 July 2025, DBT has committed to …
Accepted
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: DBT sees clear advantages of the recommendation but recognises that options to improve future delivery of redress will need to be carefully considered and the feasibility of an independent body will need to be properly …
Noted
POH-16 — Clarify whether HCRS and OCS assessment processes differ
Recommendation: The Department shall make a public announcement in which (a) it clarifies whether there will be any differences in the process for assessing financial redress, between the merged HCRS and OCS, and the process currently operating in OCS and if …
Gov response: DBT confirms that the HCRS will apply the same principles as the previous OC scheme, ensuring no OC claimant is disadvantaged by the transfer to HCRS. DBT has published further guidance on GOV.UK about the …
Accepted
POH-15 — Set deadline for HSS claims with guidance on late applications
Recommendation: No claims for financial redress under HSS shall be entertained after midnight 27 November 2025.
Gov response: DBT broadly accepts this recommendation and agrees with the need for finality. However, postmasters who have yet to submit their claim will need sufficient notice of the closure date. The Post Office will send a …
Accepted
POH-14 — Post Office to engage in negotiations during HSSA appeal period
Recommendation: During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated …
Gov response: Prior to the publication of the Inquiry’s report, DBT had been in discussion with claimants’ legal representatives about the deadlines for submission of HSS Appeals. In the light of the representatives’ concerns, DBT has agreed …
Accepted
POH-11 — Apply best offer principle equally in GLOS
Recommendation: The "best offer" principle which will apply in HSSA, as explained in response to Recommendation 10, shall be equally applicable in GLOS.
Gov response: The minister announced on 8 July that DBT would adopt a best offer principle at panel stage on the GLO, HSSA and HCRS schemes. DBT consulted the Advisory Board, Sir Ross Cranston and claimants’ legal …
Accepted
MAI-169 — Review Operation Plato guidance
Recommendation: Those organisations should consider what changes need to be made to the Counter Terrorism Policing Headquarters Operation Plato guidance in order to achieve those aims.
Gov response: Accepted in full
Accepted
MAI-166 — Introduce Major Incident Triage Tool
Recommendation: The team led by Philip Cowburn has devised a tool that is designed to replace the existing systems of primary and secondary triage. It is known as the Major Incident Triage Tool. It already has the support of NHS England. …
Gov response: Accepted in full
Accepted
MAI-162 — Define BTP Senior Duty Officer role in Major Incidents
Recommendation: The role of the Senior Duty Officer in a Major Incident should be clearly defined and explained in the British Transport Police Major Incident Manual. This role should have a corresponding action card.
Gov response: Accepted in full
Accepted
MAI-158 — Guidance on commander location during incidents
Recommendation: The Home Office, the National Ambulance Resilience Unit, the College of Policing and the Fire Service College should develop guidance as to where commanders should locate during a spontaneous Major Incident. Steps should be taken to ensure that a consistent …
Gov response: Accepted in full
Accepted
MAI-145 — Strategic Co-ordinating Group within two hours
Recommendation: The Home Office should consider the introduction of a national standard requiring a meeting of the Strategic Co-ordinating Group to take place no more than two hours after the declaration of a Major Incident where more than one emergency service …
Gov response: Accepted in full
Accepted
MAI-144 — Mandatory Ambulance Liaison Officer at events
Recommendation: The Home Office should consider how the presence of an Ambulance Liaison Officer in appropriate circumstances may be made mandatory. This may need to be put on a statutory footing.
Gov response: Accepted in full
Accepted
MAI-141 — Nationally agreed format for all emergency plans
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unity, individual police services and JESIP should develop a nationally agreed format for all plans, …
Gov response: Accepted in full
Accepted
MAI-140 — Review Major Incident plans for interoperability
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit, individual police services and JESIP should review what changes need to be made to …
Gov response: Accepted in full
Accepted
MAI-139 — Review and update JESIP Joint Doctrine
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College, the National Ambulance Resilience Unit and JESIP should review and, as necessary, update the Joint Doctrine: The Interoperability Framework …
Gov response: Accepted in full
Accepted
MAI-135 — Action cards for emergency services in Major Incidents
Recommendation: The Home Office, His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, the College of Policing, the Fire Service College and the National Ambulance Resilience Unit should oversee the development and implementation of action cards for the police, fire …
Gov response: Accepted in full
Accepted
MAI-129 — Threshold for Ambulance Liaison Officer at events
Recommendation: The Home Office and the Department of Health and Social Care should consider how the threshold for a requirement that an Ambulance Liaison Officer be present at an event is to be identified.
Gov response: Accepted in full
Accepted
MAI-115 — Guidance on equipment for warm zone interventions
Recommendation: The Department of Health and Social Care, the Faculty of Pre-Hospital Care, the College of Paramedics and the National Ambulance Resilience Unit should consider issuing guidance on how to ensure that specialist paramedics take with them, into a warm zone, …
Gov response: Accepted in full
Accepted
MAI-110 — Guidance on event first aid equipment
Recommendation: The Department of Health and Social Care should consider issuing guidance on the first aid equipment that event providers should have available on the relevant premises, as well as where that equipment should be stored to ensure that it is …
Gov response: Accepted in full
Accepted
MAI-103 — Guidance on Ambulance Liaison Officer role
Recommendation: The Department of Health and Social Care and the National Ambulance Resilience Unit should consider the scope of the role of an Ambulance Liaison Officer and issue guidance to ambulance services in that regard.
Gov response: Accepted in full
Accepted
MAI-96 — Force Duty Officer not to handle media enquiries
Recommendation: The College of Policing should issue guidance to all police services to ensure the following, in the event of a Major Incident: a. The Force Duty Officer is not expected to deal with media enquiries. b. The important task of …
Gov response: Accepted in full
Accepted
MAI-75 — Operational Commander to gain situational awareness first
Recommendation: North West Ambulance Service should review its Major Incident Response Plan to make clear that the first resource on scene should assume the role of Operational Commander only once they have achieved situational awareness.
Gov response: Accepted in full
Accepted
MAI-67 — NWAS policy for relieving Operational Commanders
Recommendation: North West Ambulance Service should ensure that it has a policy that sets out the circumstances in which an Operational Commander may be relieved and how that should occur and be communicated to the outgoing Operational Commander and beyond.
Gov response: Accepted in full
Accepted
MAI-59 — Codify prisoner communication restrictions scheme
Recommendation: I recommend that the scheme be codified, and clear policy and guidance be published so that it can be applied consistently across the prison estate.
Gov response: Accepted in full
Accepted
MAI-53 — CPS protocol for section 35 prosecution takeover
Recommendation: I recommend that the Crown Prosecution Service establish a written protocol in relation to its approach to any application from an inquiry Chairman for a section 35 prosecution to be taken over under section 6(2) of the Prosecution of Offences …
Gov response: Accepted in full
Accepted
Prevention of Future Deaths reports(221)— showing 50 strongest matches
Jared William McDowall
Concerns: The coroner noted concerns with the transitional care cut-off weight guideline, suggesting it needed to differentiate by gestation and sex, with graphical risk presentation. There was also a need for improved joint working and staff education on hypoglycaemia and recognising unwell babies.
Response (University Hospital Bristol): • The Trust has developed a composite action plan. • Many actions described within the plan are currently underway. • The plan's implementation will be monitored through the Trust's governance … (AI summary)
Responded
Isabella Hope Hill
Concerns: The Trust's guidelines for umbilical venous catheter (UVC) insertion, specifically requiring an X-ray to confirm placement, were not followed. The coroner raises concerns about the absence of national UVC guidelines and the need for review and training.
Response (Liverpool Womens NHS): • The neonatal guideline for umbilical venous catheters was revised to include urgent assessment of catheter tip position for sudden deterioration and re-launched with new junior medical trainees. • Learning … (AI summary)
Responded
Wilhelmina Isobel Newton
Concerns: The coroner noted the absence of a clear written plan or guidance for staff regarding responses to head injuries in elderly residents, particularly those on anti-clotting medication, a gap that may affect other council-operated homes.
Response (Cumbria County Council): • Cumbria County Council has reviewed the issue of protocols for head injuries in elderly residents, particularly those on anti-clotting medication. • New guidance has been developed by Cumbria County … (AI summary)
Responded
Yousef Shokri-Gharab
Concerns: The coroner noted Mersey Care's informal patient leave policy is outdated, unreviewed since 2007, and inconsistent with current practice. It requires immediate updating to include multidisciplinary consensus, patient vulnerability considerations, and clear documentation.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team was tasked with ensuring all policies are reviewed and updated. • The policy identified by the coroner was reviewed and updated. • 50 policies were … (AI summary)
Responded
Scarlett Sinclair
Concerns: The coroner highlighted differences in how neonatal units assess a baby's stability and suitability for transfer, prompting a request to review the policy for approving inter-unit transfers.
Overdue
Keith Martin
Concerns: The coroner noted significant delays in Mr Martin's assessment, tests, and senior review in A&E, alongside concerns about the lack of appreciation for his symptoms and test results. Further issues included slow pharmacological treatment, unclear chest pain management protocols, and ineffective documentation.
Overdue
Adrian Cowan
Concerns: The trust's policy for responding to a patient collapse lacked clear guidance and did not require requesting a duty doctor. Nursing staff also did not act calmly or apply basic life support training effectively during the emergency response.
Response: • The Trust reviewed its resuscitation policy and committed to incorporating additional actions for deteriorating patients, expanding the NEWS Score, and clarifying the need to contact a duty doctor. • … (AI summary)
Overdue
Vincent Gibson
Concerns: The coroner identified a lack of clear command structure and accountability for incident management, alongside issues with communication protocols and the effective use of electronic mapping tools for resource allocation and deployment.
Overdue
Thomas Smith
Concerns: The coroner identified gaps in complete and accurate handover information between primary and secondary care, raising concerns about the prioritisation of children's cases in out-of-hours services. The report also noted a need to revisit national guidance on pre-hospital antibiotics for suspected meningitis and highlighted a fragmented approach to patient care in hospitals where nursing staff concerns were not promptly acted upon.
Overdue
Nathan Healer
Concerns: The coroner raised concerns regarding the delay in finalising new NICE guidance on diabetes in pregnancy, specifically whether it can be expedited. There was also a recommendation to revisit existing guidance if new recommendations are not forthcoming.
Response (Department of Health): • The Department of Health stated that draft guidance for NICE Guideline CG63 was scheduled for consultation in September 2014. • The Department of Health indicated that the finalised guidance … (AI summary)
Responded
Faye Rippon
Concerns: The coroner noted concerns that hospital protocols for foeticide before induction of labour do not allow its use at 21/40 gestation, which results in live births following late terminations. This situation is distressing for both staff and parents.
Overdue
Clive Turner
Concerns: The coroner noted a junior doctor's lack of awareness regarding prior pain relief from the ambulance service and hospital policies for overnight discharge. Concerns were also raised about the absence of senior clinicians for second opinions late at night.
Response (Welsh Ambulance Service NHS Trust): • The Trust developed a process for escalating calls with delayed ambulance responses to gain additional clinical assistance from NHS Direct Wales, which is scheduled to be in place by … (AI summary)
Responded
Caroline Carter Crowther
Concerns: There was a significant difference in understanding among paramedics and management regarding the Trust's policy on compelling psychiatric patients to hospital, particularly concerning the use of physical coercion without police presence.
Overdue
Elouise Winship
Concerns: The coroner identified the absence of a documented regime for regular fetal heart auscultation after opiate administration to mothers. There were also concerns that further examinations and observations were not consistently undertaken following a change in the mother's condition.
Overdue
Elsie Plumb
Concerns: The coroner noted concerns about the clarity of national guidance from the Royal College of Obstetricians and Gynaecologists regarding the administration of antibiotics to mothers for Group B Streptococcal Disease, particularly when induction of labour is involved.
Overdue
Phyllis Kerry
Concerns: The coroner noted a lack of clear guidelines for managing intra-cerebral bleeds in patients on Warfarin, an absence of clarity on specialty responsibility for reversal decisions, and insufficient communication of relevant guidelines to staff.
Response (Nottingham University Hospitals NHS Trust): • Discussions were held between relevant specialties to optimise the management of patients with intra-cerebral bleeds. • A new guideline has been prepared to provide more rapid intervention in anticoagulation … (AI summary)
Response (Nottingham University Hospitals NHS Trust2f): • A new guideline for the prompt and appropriate treatment of patients on Warfarin presenting with Intra Cranial Haemorrhage has been agreed and provided. • Heads of Service have been … (AI summary)
Responded
Francoise Snape
Concerns: The coroner identified the absence of a VTE assessment for Mrs. Snape, attributed to staff workload and a belief it was unnecessary. This, along with insufficient consideration and knowledge of NICE guidelines for mechanical anti-DVT devices, presented missed opportunities in her care.
Overdue
Mohammed Yousaf
Concerns: The coroner noted the absence of national guidelines for interpreting antenatal CTG tracings and raised concerns about the dissemination and application of the Trust's local interpreting policy, especially regarding informed consent.
Overdue
Lexie Harrison
Concerns: Sheffield Children's and Leeds Teaching Hospitals NHS Trusts lack specific policies for paediatric oesophageal varix banding, and there are no national guidelines for this procedure, leading to varied practices among consultants.
Response (The Leeds Teaching Hospitals NHS Trust): • The Trust confirmed it had local guidelines for the management of bleeding oesophageal varices and for post-operative care, which it had shared with referring Trusts. • The Trust stated … (AI summary)
Response (Cardiff and Vale University Health Board): • The respondent stated they were unable to directly address the concerns regarding policies for paediatric oesophageal varix banding or national guidelines. • The respondent suggested directing the concerns to … (AI summary)
Overdue
Paige Bell
Concerns: The coroner identified fragmented patient case notes and queried plans for immediate electronic access, alongside the need for a national policy for engagement and observation. Concerns were also raised regarding updated guidance for the treatment and management of Borderline Personality Disorder.
Response (Northumberland Tyne Wear NHS Trust): • The Trust developed a new Engagement and Observation Policy, which emphasizes clinical assessments and patient engagement. • Staff received reiteration and training on the importance and correct completion of … (AI summary)
Response (Department of Health): • The Summary Care Record (SCR) system is in place to provide healthcare staff with electronic access to essential patient information. • NHS England is planning to update its Suicide … (AI summary)
Responded
Michael Pollard
Concerns: An outdated on-call rota used by the hospital switchboard caused delays in contacting the correct consultant for an emergency endoscopy. The coroner identifies a need for an up-to-date, centrally managed rota accessible to all relevant staff.
Response (University Hospitals of Leicester NHS Trust): • The Interim Medical Director wrote to all doctors reminding them of their obligations to inform switchboard of any amendments to the on-call rota. • The Director of Estates and … (AI summary)
Responded
David Bladen
Concerns: The coroner identified an absence of guidance for optimal thromboprophylaxis management in patients with restricted mobility due to a brace, particularly when they are not in casts.
Response (National Institute for Health and Care Excellence): • The Guideline Development Group agreed a research recommendation to increase knowledge regarding post-operative care. • The guideline is to be updated as part of a routine surveillance process, and … (AI summary)
Responded
Thomas Beaty
Concerns: The coroner identified that instrumental delivery guidance from the Royal College of Obstetricians and NICE was ambiguous, misleading, and lacked clear definitions for key terms like 'imminent' and 'gentle' traction. This ambiguity complicated decision-making during procedures and hindered the development of clear local Trust guidance.
Response (Department of Health): • The Department of Health sent a copy of the coroner's report to the Royal College of Obstetricians and Gynaecologists (RCOG). • The report was sent to make the RCOG … (AI summary)
Response (Pennine Acute Hospitals): • The Trust revised its Guideline for Assisted Vaginal Delivery to provide greater clarity on consultant presence for trials in theatre and added guidance on flexion points, complications, and disimpaction. … (AI summary)
Overdue
Michael Quinn
Concerns: The coroner notes confusion regarding appropriate pre-operative blood glucose levels for surgical patients, as the hospital's policy differed from national guidelines and published research. The Trust is asked to review its recommended levels.
Overdue
Dean Joseph
Concerns: The coroner noted inconsistent understanding among officers regarding armed containment, a lack of guidance from trained hostage negotiators for untrained officers, and post-incident management procedures that eroded public confidence and hampered learning.
Response: • The Metropolitan Police Service (MPS) committed to enhancing training for firearms officers and commanders on armed containment types, communication, and the early deployment of trained negotiators. • The National … (AI summary)
Responded
Glenda Day
Concerns: The coroner notes concerns regarding the process of granting home leave without a recent doctor's review or updated risk assessment. The report identifies a lack of clear, trust-wide policy detailing specific requirements, staff awareness, and auditing for adherence.
Overdue
Stefen Boswell
Concerns: The coroner notes inconsistencies between West Mercia Police's policy and national guidance on wrong-way dual carriageway pursuits, impacting officer training. A lack of explicit communication protocols between pursuing officers and supervisors during high-risk tactics was also identified.
Response (West Mercia Police): • West Mercia Police and Warwickshire Police aligned pursuit policies and training with the College of Policing's Authorised Professional Practice (APP). • The forces implemented a single Operational Control Centre … (AI summary)
Pending
Carl Dickerson
Concerns: The coroner noted that regulations preventing take-off in challenging conditions from licensed commercial aerodromes do not apply to non-commercial flights from unlicensed aerodromes. This regulatory gap persists despite a similar accident in the 1990s and prior recommendations for establishing a special category for corporate aviation.
Response (CAA): • The Civil Aviation Authority (CAA) published Safety Notice SN-2014/006 and produced CAP 686 to provide guidance for private and corporate helicopter operations. • The CAA instigated a review of … (AI summary)
Responded
Douglas Kay
Concerns: The coroner identified significant confusion and uncertainty regarding policies for transferring patients with gastrointestinal bleeding within the Trust. Senior staff at Bassetlaw Hospital were also unaware of the new Doncaster Hospital service's operational details, particularly out of hours.
Response (DBH Trust): • A new Upper GI Bleed Transfer Policy for Bassetlaw Hospital has been developed. • All staff will be made aware of the transfer policy through the Clinical Site Manager … (AI summary)
Responded
Joseph Sarkozi
Concerns: The coroner noted fire officers concluded dust on light fittings caused smoke and a burning smell without positive evidence, recommending national dissemination of learning on this risk.
Response (Avon Fire PFD): • The incident scenario will be included in training packages for operational crews, commencing this April. • Information will be shared via the "Fire Alert" system and distributed to the … (AI summary)
Overdue
Wilfred Pearson
Concerns: The coroner noted concerns about the Status Epilepticus protocol's dissemination, inadequate medical notes, and care escalation understanding. The legal authority for detaining an agitated patient without proper authorisation was also questioned.
Response (W Pearson): • The Trust revised its Status Epilepticus policy, integrated it into junior doctor training, and ensured its availability on the intranet. • The Trust reviewed medical staffing rotas, implemented recruitment … (AI summary)
Responded
Derrick Twiate
Concerns: The coroner noted that pharmacists in general practices continue to snip tablets from unit dose packs into multi-dose compliance aids, a practice contrary to professional body advice.
Overdue
Curt Falk
Concerns: The coroner noted that current vaccination policy does not include males against a viral infection, which poses a risk of future deaths in men from the consequences of this infection.
Response (JCVI): • The Joint Committee on Vaccination and Immunisation (JCVI) established an HPV sub-committee in October 2013 to consider extending the HPV vaccination programme to adolescent boys and men who have … (AI summary)
Overdue
Christ Morrison
Concerns: The coroner noted concerns regarding the required training levels for staff changing children's tracheostomy tubes and the lack of medical presence during the procedure. The policy for failed tube replacement directs emergency transfer instead of an on-site emergency tracheostomy.
Response (Epsom and St Helier NHS Trust): • The Trust updated its Paediatric Tracheostomy Policy in 2016 to require two nurses to attend when families request support for tube changes from the community team. • The Trust … (AI summary)
Overdue
Edward Paddon-Bramley
Concerns: A divergence exists in guidelines and practice between hospital Trusts and consultants compared to National Institute for Health and Care Excellence (NICE) recommendations for managing prolonged rupture of membranes and Group B Streptococcus screening in pregnant women, particularly concerning antibiotic usage.
Response (NSC): • The UK National Screening Committee (UK NSC) commissioned an update review into antenatal screening for Group B Strep (GBS) in December 2015. • A public consultation on GBS screening … (AI summary)
Response (Department of Health): • The Department of Health and Public Health England are undertaking studies and monitoring developments related to Group B Strep (GBS) prevention and screening. • The Royal College of Obstetricians … (AI summary)
Overdue
Marjorie Booth
Concerns: The coroner raised concerns regarding a hospital policy that does not routinely perform CT scans for elderly patients with suspected fractures due to radiation risk, despite the higher risk of missing such injuries. The report asks if this policy can be amended.
Overdue
Alan Dimbleby
Concerns: The report identifies a risk from the absence of operator seat restraints in self-propelled sprayers, as operators can be thrown from the vehicle during an overturn. It suggests revising HSE guidance which indicates restraints may not be needed for these vehicles.
Response (Bateman Engineering Ltd): • Bateman Engineering Ltd has changed the design of its sprayer cabs to include operator seat restraints. • All new vehicles leaving the workshop are now fitted with operator seat … (AI summary)
Response (Alan DIMBLEBY): • The Health and Safety Executive (HSE) stated it cannot advocate a policy requiring all self-propelled sprayers to be fitted with seat restraints, explaining that restraints are not recommended for … (AI summary)
Overdue
Mark Seward
Concerns: The coroner identified a lack of clarity regarding pressure testing activities and raised questions about compliance with work equipment regulations and HSE guidance across the industry.
Response (SEWARD): • The company reviewed all risk assessments, COSHH assessments, and safe systems of work, and delivered toolbox talks to employees. • A new Safety Officer/Assistant Manager was appointed, and the … (AI summary)
Responded
Helen Patton
Concerns: Concerns were raised regarding the mortality risk associated with Mini Tracheostomy Procedures performed outside theatre or without ultrasound guidance, and the lack of national guidance for these procedures.
Response (Department of Health): • The Department of Health referenced existing national guidelines and reports concerning safe tracheostomy procedures, including publications from NICE, NCEPOD, NTSP, and RCOA. • The Royal College of Anaesthetists and … (AI summary)
Response (The Royal College of Anaesthetists): • The Faculty and College supported the NCEPOD recommendation that insertion of any device for front of neck airway access is classed as a surgical procedure. • The Faculty and … (AI summary)
Responded
Henry Hicks
Concerns: The coroner noted a discrepancy between police officers' assessment of a situation and the jury's determination that it constituted a police pursuit, implying non-compliance with Metropolitan Police Service procedures for seeking authorisation.
Response (Metropolitan Police Service): • The four principal officers involved in the incident have been referred to gross misconduct proceedings. • The Metropolitan Police Service reviewed its wider practices and protocols, including existing guidance, … (AI summary)
Responded
Khazna Khalaf
Concerns: The coroner raised concerns regarding the effectiveness of hospital protocols and guidelines for identifying ecstasy toxicity risks and symptoms, and the appropriateness of clinical protocols for initial intervention and patient monitoring.
Overdue
Robert Dearing
Concerns: The coroner noted that unregulated, non-standard anti-glare visors significantly reduced driver vision due to low Visual Light Transmission, and there is no specific legislation or British Standard for such devices.
Overdue
Samantha Hopkins
Concerns: The coroner noted that PARAMEDIC 2 Trial exclusion criteria, including for pregnant women, were overlooked due to insufficient prominence on drug packets. There was also a lack of guidance from Warwick Medical School on how to highlight these exclusions to participants.
Response (South Central Ambulance Services NHS Trust): • The Trust collaborated with the University of Warwick to design a new label detailing exclusion categories for trial drug packs. • The new label design will be affixed to … (AI summary)
Response (Warwick Medical School): • The University stated it would include all four exclusion criteria on new labels for Investigational Medicinal Products (IMP) packaging. • The University confirmed that new labels would be distributed … (AI summary)
Responded
Denis Cronin
Concerns: Concerns were raised regarding the absence of training records, deviations from standard diving practices and depths, and a lack of written risk assessments for the dive. Additionally, an unqualified instructor led the dive, and a problematic dive belt configuration was noted.
Response (Denis Cronin Response2): • BSAC is rewriting its Diver Training Programme to include individual skill sign-off sheets and is developing a digital platform for training records, with initial syllabus revisions planned for early … (AI summary)
Response (Denis Cronin): • The club will develop a method for recording partial training completion. • Instructors have been reminded about instruction and supervision levels and will be reminded to follow BSAC guidance … (AI summary)
Responded
Colin Wellings
Concerns: The coroner raised concerns that domestically manufactured machines from 1973, exempt from helmet and seatbelt requirements, pose an inherent risk. The report suggests considering legislation to bring this class of vehicle in line with other mechanically propelled vehicles.
Response (Department for Transport): • The Department for Transport proposes to ask for tricycle casualties on public roads to be recorded separately in police reported road casualty statistics (Stats 19). • This change is … (AI summary)
Responded
Nihad Ousta
Concerns: The coroner noted the absence of a protocol or written guidance for managing head injuries, including specified frequencies and ranges for general and neurological observations.
Overdue
Barbara Turner
Concerns: The coroner noted that the resuscitation team call-out criteria in the Trust's policy are too broad, potentially delaying intervention for critically ill patients. Concerns were also raised about the unsafe method of patient transfer to and from the CT scanner, which lacked appropriate medical escort and equipment.
Overdue
Frederick Squires
Concerns: The coroner noted a lack of guidance for clinicians on when to recommence Warfarin for patients who have suffered a head injury, which risks patients developing bleeds or strokes.
Response (National Institute for Health and Care Excellence): • NICE stated it would consider extending the scope of its head injury guideline to include recommendations on reintroducing Warfarin, when the guideline is updated in 2017. (AI summary)
Responded
James Fox
Concerns: Concerns were raised regarding the accuracy of close-range firearm use, the lack of less lethal firearms or ballistic shields, and insufficient contingency planning. The coroner also noted inconsistencies in police training curricula and the absence of national standard training.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) maintains national standards for armed officers' weapon handling and shooting accuracy. • The MPS regularly reviews these standards to ensure officers are trained to … (AI summary)
Responded
Joyce Crompton
Concerns: The coroner identified a lack of written policy, systematic checklist, and refresher training regarding referrals to the Speech and Language Therapy (SALT) team after choking incidents, which resulted in missed referrals on two occasions.
Response (Belong): • Managers and nurses were reminded of the importance of following the organisation's policies and procedures. • Staff were requested to reassess all residents' risk of choking and ensure follow-up … (AI summary)
Responded
Select committee recommendations(84)— showing 50 strongest matches
#90 —
Recommendation: The Government should review the potential uses of standardisation in house building and how current practice and the building regulations may need to change to facilitate this.
#15 —
Recommendation: The Government should review the potential uses of standardisation in house building and how current practice and the building regulations may need to change to facilitate this.
#84 —
Recommendation: The Government should develop integrated plans for addressing all areas of conflict between development and environmental policies before legal backstops are reached and development is halted. These must include implementation plans and be in line with the environmental principles policy …
Response attribution not verified
#80 —
Recommendation: It is unclear how this plan will be implemented. John Curtin, interim Chief Executive of the Environment Agency, suggested that resolving the implementation approach for the IPW would require political decisions on the balance of responsibility between sectors for addressing …
Response attribution not verified
#76 —
Recommendation: The full suite of environmental regulations delivered through the planning system should be reviewed and, if necessary, considered for amendment to ensure that they are in line with the Government’s environmental principles policy statement. Addressing nutrient pollution
Response attribution not verified
#74 —
Recommendation: The Government should review the range of ecological assessments required of developers. It should issue guidance to local planning authorities on which assessments can be discretionary for smaller sites, rather than required up front. (Paragraph 224) < Back Next > …
Response attribution not verified
#71 —
Recommendation: Allowing local planning authorities to require biodiversity net gain ahead of the delayed statutory deadline negates the benefit of this accommodation. Where the Government has announced a transition period and implementation date local planning authorities should not be able to …
Response attribution not verified
#67 —
Recommendation: By the end of 2023 , the Government should publish its timeline for reviewing and updating all National Policy Statements. (Paragraph 206) Impact on smaller developers
Response attribution not verified
#66 —
Recommendation: Given the impact of uncertainty in the planning system on the delivery of new homes, the Government should ensure that policy is communicated clearly and in a timely manner. For a transition period to be successful stakeholders need to know …
Response attribution not verified
#65 —
Recommendation: We are sympathetic to the fact that the use of secondary legislation will allow for regulations and policy to respond to the “fast-changing nature of environmental science”. This does not preclude the Government from setting out how the policy will …
Response attribution not verified
#63 —
Recommendation: We were disappointed to learn of the Government’s decision to not consult on nutrient and water neutrality guidance despite time being available. This choice was unnecessary and led to serious ramifications. It is indicative of a wider issue: communication on …
Response attribution not verified
#55 —
Recommendation: To create consistency for developers and improve community engagement with the planning process, the Government should develop templates and exemplars for those assessments most regularly undertaken by developers .
Response attribution not verified
#7 —
Recommendation: If the Government thinks it is appropriate for competent authorities to be responsible for balancing economic, social and environmental priorities at permission stage, it must ensure that the necessary expertise is available within local authorities. Detailed guidance on the process …
Gov response: The Government agrees that highly skilled planners are fundamental to proactive local planning, securing high quality local design and placemaking, and running an efficient planning service for the communities they serve. They are invaluable in …
Accepted
#6 —
Recommendation: As a result of the requirement to mitigate harm at a project level, local planning authorities are attempting to balance decisions between unequally weighted principles. To overcome the statutory weight of environmental protection requires significant expertise and places great additional …
Response attribution not verified
#62 —
Recommendation: Author visits to schools and other education settings can be transformational in inspiring young readers and helping children see the person behind the magic. The Department for Education should develop resources for schools and early years settings with clear points …
Response status not verified
#61 —
Recommendation: The Department for Education should publish guidance for schools and early years settings outlining how they should work with the wider literary industry, including visits to public libraries, author visits, links with local bookshops, and the publishing industry. (Recommendation, Paragraph …
Response status not verified
#1 —
Recommendation: We were unconvinced by the evidence we received from the supermarkets regarding their concerns about the updated nutrient profiling model. The NPM underpins all the government’s regulatory action to prevent obesity, yet the version of the model being used is …
Response status not verified
#3 —
Recommendation: The Government should publish one consolidated, regularly updated “business-facing” guidance source for the EPD, the Technology Prosperity Deal and the Pharmaceutical Arrangement. This guidance should distinguish between the tariff and customs requirements currently in force and what remains under negotiation …
Response status not verified
#2 —
Recommendation: The UK Government has responded to US tariff policy as fast as a volatile environment allows, and has brought welcome stability to some trade terms. However, the agreements remain frameworks with language open to divergent interpretation, and their durability subject …
Response status not verified
#40 — Commission NICE to develop and disseminate comprehensive guidelines for all reproductive health conditions, monitoring adherence.
Recommendation: The Department of Health and Social Care and NHS England should commission NICE to develop comprehensive guidelines for all reproductive health conditions. Those guidelines should be communicated to GPs and made accessible to patients through the NHS website to allow …
Response attribution not verified
#5 — Specify in statutory guidance that boys must be taught female reproductive health conditions
Recommendation: The statutory guidance should specify that boys should be taught about female reproductive health conditions.
Response attribution not verified
#33 — Current highway infrastructure Code of Practice contains significant gaps, requiring urgent updates.
Recommendation: The Department told us that Ministers are considering a review of the Code of Practice as it considers there to be value in doing so, even though it will be major task to update the more than 260-page document. The …
Response attribution not verified
#32 — Department provides outdated guidance for local authorities on road network maintenance.
Recommendation: The Department is responsible for providing guidance to local authorities in England to help them run and maintain their road networks, but has not updated its guidance for several years.70 Such guidance has included good practice proactive maintenance to reduce …
Response attribution not verified
#6 — Update and regularly revise local road guidance to reflect best practices and new challenges.
Recommendation: The Department has not provided enough support and guidance to local authorities to deal with current and future challenges in maintaining local roads. The Department is responsible for providing local authorities with guidance on the management and maintenance of local …
Response attribution not verified
#36 — Provide clear guidance for commissioning research coherent with hunger-fighting aspirations and food systems.
Recommendation: The Government needs to ensure that research is coherent with its aspirations to fighting hunger and considers the inter-related factors facing nutrition and food systems. As part of the Zero Hunger delivery framework there should be clear guidance on this …
Response attribution not verified
#7 — Urge Ministers to issue revised Marine Policy Statement by January 2026 reflecting pressures
Recommendation: We urge Ministers to issue a revised Marine Policy Statement no later than January 2026. The updated statement should reflect the current and evolving pressures on the marine environment, clearly outline the Government’s priorities for marine usage, and set out …
Response attribution not verified
#6 — Update the outdated Marine Policy Statement at the earliest opportunity
Recommendation: The current Marine Policy Statement is outdated, not fit for purpose and no longer reflects Government policy or pressures on the marine environment. It therefore must be updated at the earliest opportunity. (Conclusion, Paragraph 33)
Response attribution not verified
#13 — Increase long-term public contract opportunities; update procurement strategy with comply-or-explain for UK products.
Recommendation: To ensure that there is sufficient long term demand signalling, we recommend that Government Departments increase the proportion of public contract opportunities in their pipeline that are five to ten years out. . We also recommend that the Government update …
Response attribution not verified
#9 — Provide clear framework for DBT overseas teams to support priority sector export opportunities.
Recommendation: We recommend that Department for Business and Trade teams based abroad are given a clear framework, which they report to Parliament, for how they can support export opportunities for each of the growth driving sectors, in the most important UK …
Response attribution not verified
#34 — Government's static technology requirements and lack of contract agility hinder digital commercial activity
Recommendation: The NAO found that government will need to adopt wide–ranging changes to how it approaches digital commercial activity, which reflect the changing reality of technology markets. For example, it will need to understand its negotiation levers more fully, understand more …
Response attribution not verified
#22 — Government's digital commercial playbook requires significant enhancement and broader consultation for effectiveness.
Recommendation: The GCF accepted that the playbook needed to be enhanced and improved, and said that in doing so it would involve GDS. It explained that its aim was to ensure that the playbook was “really fit for purpose”, in terms …
Response attribution not verified
#21 — Digital, Data and Technology Playbook lacks detail on assessing large project technical feasibility
Recommendation: The government has published a ‘Digital, data and technology playbook’, which sets out key policies and guidance for how digital projects are assessed, procured and delivered.33 We asked whether this would be the primary tool for driving some of the …
Response attribution not verified
#12 — Centre of Excellence expected to refresh digital playbook and produce sourcing strategy
Recommendation: During our evidence session, the Cabinet Office and DSIT identified a range of other areas that they expected the new Centre of Excellence to contribute to. For example, the GCF recognised that it needed to do “a lot more” to …
Response attribution not verified
#7 — Government's technology market approach lags, requiring tailored sourcing strategies.
Recommendation: We therefore asked how government was keeping up with the pace of change in technology markets, and when we could expect a coherent strategy in response. DSIT recognised that there was currently a gap between the market in which it …
Response attribution not verified
#2 — Set out Digital Commercial Centre of Excellence's plans and resource balance for activities.
Recommendation: The Cabinet Office and DSIT have many expectations for the Digital Commercial Centre of Excellence to deliver the large–scale improvements needed to current digital commercial activities, as well as its existing aims. Government’s current digital commercial approaches and practices require …
Response attribution not verified
#73 — Utilise HMS Protector more effectively for Antarctic logistics, enhancing MOD/BAS collaboration.
Recommendation: HMS Protector should be utilised more effectively to support the logistical needs of Antarctic research bases, similar to the role of US military and Coast Guard support for US stations. This could allow the RRS Sir David Attenborough to focus …
Response attribution not verified
#72 — Conduct comprehensive review of NERC's 'single vessel plus' policy by 2030.
Recommendation: By 2030, the Natural Environment Research Council should conduct a comprehensive review of the “single vessel plus” policy, evaluating its impact on Antarctic and Arctic marine science, particularly regarding the delays to approved research projects. The review should focus on …
Response attribution not verified
#71 — Prioritise RRS Sir David Attenborough for dedicated research, chartering logistics vessels where possible.
Recommendation: We have heard strong concerns from the Antarctic research community about the Natural Environment Research Council’s (NERC) shift to a “one ship plus” model and the reduction of the research fleet from two vessels to one. This has already led …
Response attribution not verified
#14 — Clarify National Policy Statements to permit adjustments to electricity transmission strategic parameters when justified.
Recommendation: The National Policy Statements should clarify that adjustments may be made to the “strategic parameters” for new electricity transmission infrastructure set out in the Centralised Strategic Network Plan where this is justified following detailed design development, community consultations or environmental …
Response attribution not verified
#13 — Review and amend EN-1 guidance endorsing CSNP for clarity and consistent language.
Recommendation: The Government should review and, if necessary, amend the proposed guidance endorsing the CSNP in paragraphs 3.3.78 to 3.3.80 of EN-1, to make the language more consistent, unambiguous, and more in keeping with current understandings of the intended purpose of …
Response attribution not verified
#12 — Guidance on Centralised Strategic Network Plan endorsement in EN-1 remains unclear.
Recommendation: We welcome the decision to endorse the Centralised Strategic Network Plan (CSNP) in the National Policy Statements. However, we are concerned that the proposed guidance in paragraphs 3.3.78 to 3.3.80 of EN-1 is not clear enough about what, precisely, it …
Response attribution not verified
#11 — Strengthen NPS guidance on grid connection weight and clarify future connection prospects assessment.
Recommendation: The National Policy Statements should give significant weight to the availability of a grid connection, as a paramount consideration in determining where electricity generation projects can be located. However, by the same token, where a project has not yet secured …
Response attribution not verified
#9 — Clarify specific family group decision-making model within statutory guidance for consistent practice.
Recommendation: The Department should clarify the specific model of FGDM in statutory guidance to ensure that best practice is followed in all local authorities. (Recommendation, Paragraph 22)
Response attribution not verified
#22 — Work with industry to prevent UK-US economic alignment creating unintended trade obstacles.
Recommendation: The Government should work closely with industry to ensure that closer UK– US alignment on economic security measures, such as investment screening and export controls, does not create unintended obstacles for legitimate trade and collaboration. It should provide clear guidance …
Response attribution not verified
#21 — Adopt hybrid BCP/PoD plant inspection model and share biosecurity protocols for inland BCPs.
Recommendation: The Government should adopt the Horticultural Trades Association’s proposal for a hybrid inspection model, combining BCP and PoD approaches. Following a short consultation with industry, the Government should designate specific consignments eligible for PoD inspections. Additionally, APHA should share with …
Response attribution not verified
#6 — Airport expansion plans based on outdated ANPS, inconsistent with current government objectives.
Recommendation: We are concerned that airport expansion plans will have been produced prior to the publication of a new ANPS which ought to be in place to provide the airports with strategic guidance. We are also deeply concerned that, given a …
Response attribution not verified
#11 — Decent Homes Standard previously outdated and in urgent need of reform
Recommendation: We welcome the Government’s changes to the Decent Homes Standard. The current standard has been out-of-date for some time and is in urgent need of reform, given that it was last updated in 2006. (Conclusion, Paragraph 48)
Response attribution not verified
#14 — Ambiguity in assessing and enforcing Clause 18 duties for GBR, SoS, and ORR.
Recommendation: It is not clear from the Bill how the Secretary of State, GBR and the ORR will be assessed on how they fulfil their clause 18 duties or how the duties will be enforced should they fall short. There is …
Response attribution not verified
#13 — Mandate Secretary of State to publish statutory guidance for GBR on weighing competing duties.
Recommendation: As GBR is accountable to the Secretary of State for fulfilment of its duties, we recommend the Secretary of State issues and publishes statutory guidance on how GBR, at least, should weigh up competing elements of the duties. This will …
Response attribution not verified
#12 — Ensure statutory guidance includes details on how ORR should balance GBR duties.
Recommendation: There are benefits to unified duties but the Bill is insufficiently clear on how they will operate in decision-making, in particular the weighting to be assigned to each factor. The Office of Rail and Road will enforce GBR’s business plan …
Response attribution not verified
HSSIB safety recommendations(16)
Residual drugs in intravenous cannulae and extension lines
HSIB recommends that the Royal College of Anaesthetists reviews its 'Guidelines for the provision of anaesthetic services' regarding the planning and oversight of perianaesthetic care in non-theatre settings. This should include: guidance to assist anaesthetic departments to consistently plan for …
Safety Recommendation
Residual drugs in intravenous cannulae and extension lines
HSIB recommends that the Royal College of Anaesthetists and Centre for Perioperative Care work with relevant stakeholders - such as the Association of Anaesthetists, College of Operating Department Practitioners, and Association for Perioperative Practice - to review, update and integrate …
Safety Recommendation
Suitability of equipment and technology used for continuous fetal heart rate monitoring
HSIB recommends that NHS England and NHS Improvement amends the ‘Saving Babies’ Lives care bundle version 2’ to remove specific references to Dawes-Redman and instead use a generic term such as ‘computerised cardiotocograph (CTG) analysis’.
Safety Recommendation
Timely detection and treatment of cauda equina syndrome
HSIB recommends that the National Institute for Health and Care Excellence updates its current low back pain guideline to include the symptoms and initial management of cauda equina syndrome. This update should include a review of the role of supplementary …
Safety Recommendation
Advanced airway management in patients with a known complex disease
The British Inherited Metabolic Diseases Group has amended the content of their guidance with specific reference to specialist guidance from the Royal College of Anaesthetists and the Difficult Airway Society in relation to videolaryngoscopy and incorporating reference to both planned …
Safety Action
Advanced airway management in patients with a known complex disease
HSSIB recommends that the Royal College of Anaesthetists makes changes to its Guidelines for the Provision of Anaesthetic Services (GPAS) requirements for all anaesthetists, to include guidance on: requirements for anaesthetists to have access to videolaryngoscopes in all locations where …
Safety Recommendation
Advanced airway management in patients with a known complex disease
HSSIB recommends that the Royal College of Anaesthetists works with the Difficult Airway Society and other key stakeholders to produce a framework on the management of a potentially ‘life threatening’ difficult airway for people with a known difficult airway who …
Safety Recommendation
Retained swabs following invasive procedures: themes identified from a review of NHS serious incident reports
Original safety recommendation: HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using human factors …
Safety Recommendation
Investigation report: Retained swabs following invasive procedures
HSSIB recommends that the Centre for Perioperative Care (CPOC) and Association for Perioperative Practice (AfPP) work together with other key stakeholders to review and amend the process and standards for the reconciliation of swabs, using human factors expertise and user-centred …
Safety Recommendation
Interim report: Retained swabs following invasive procedures
Organisations can improve patient safety by using consistent terminology in national and local guidance when describing the responsibility for the reconciliation of items used in surgery and invasive areas, including swabs. How is information about swabs communicated? Challenges in communication …
Safety Observation
Patients at risk of self-harm: continuous observation
HSSIB recommends that NHS England, working with relevant stakeholders, produces national guidance for staff undertaking continuous observation of mentally unwell adult patients, along with a training and competency framework to provide staff with the necessary skills for this intervention in …
Safety Recommendation
Healthcare provision in prisons: continuity of care
HSSIB recommends that HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released …
Safety Recommendation
Residual drugs in intravenous cannulae and extension lines
Where certain drugs are used during an anaesthetic, such as NMBAs and some strong opioids, flushing becomes a safety-critical task. However, the task of flushing is functionally the same and there are limited additional steps or process alterations that mark …
Learning Prompt
Suitability of equipment and technology used for continuous fetal heart rate monitoring
HSIB recommends that the National Institute for Health and Care Excellence considers reviewing its telemetry recommendation as part of the current update of clinical guideline CG190, taking into account the existing evidence and the findings of this report.
Safety Recommendation
Temporary staff – involvement in patient safety investigations
HSSIB recommends that NHS England includes guidance on engaging temporary staff in learning responses within their 'engaging and involving patients, families and staff following a patient safety incident'. This should be developed in collaboration with providers of temporary staff to …
Safety Recommendation
Residual drugs in intravenous cannulae and extension lines
The WHO surgical safety checklist is an administrative control used to mitigate residual drugs in cannulae and extension lines following anaesthesia. Items on the WHO checklist act as prompts for expected actions or tasks, and do not include second/independent checks …
Learning Prompt
CQC inspection actions(126)— showing 50 strongest matches
Wexham Park Hospital
The service should ensure policies and guidelines are up-to-date, and there are effective processes in place to manage them.
Should Do
Worthing Hospital
The trust must ensure that guidance documents have been reviewed and are up to date.
Must Do
West Cumberland Hospital
The trust should ensure that its alcohol withdrawal policy is reviewed and updated accordingly in a timely manner.Regulation17(2)(b).
Should Do
Watford General Hospital
The trust must ensure that policy and guidance documents are reviewed in line with the review date.
Must Do
University Hospital of Hartlepool
The trust should ensure that policies and procedures are correctly managed and reviewed in a timely way so that the latest and most appropriate guidance is always available to its staff.
Should Do
The York Hospital
The service should ensure all version-controlled documents are reviewed and in date.
Should Do
The York Hospital
The trust must ensure that the Freedom to speech up policy guidance (v11) which was passed its review date of February 2022 is updated.
Must Do
Stroud Maternity Hospital
The service must ensure there is a process to ensure oversight and management of policies, guidance, and procedures to ensure they are reviewed in a timely manner, are clear and reflect national guidance Regulation 17(1)(2)(a).
Must Do
St Richard's Hospital
The trust must ensure that guidance documents have been reviewed and are up to date.
Must Do
Scarborough Hospital
The service should ensure all version-controlled documents are reviewed and in date.
Should Do
Scarborough Hospital
The trust must ensure that the Freedom to speech up policy guidance (v11) which was passed its review date of February 2022 is updated.
Must Do
Scarborough Hospital
The trust must ensure that the guidance within all policies is up to date, accurate and relevant to the service. This includes, but is not limited to, the guidance within the workforce and equality, diversity, and inclusion (EDI), freedom to …
Must Do
Salford Royal Hospital
The trust must ensure it aligns relevant policies and procedures to reduce unwarranted variation in clinical practice, and that policies are up to date.
Must Do
Salford Royal Hospital
The trust must ensure it aligns relevant policies and procedures to reduce unwarranted variation in clinical practice, and that policies are up to date.
Must Do
Royal Hallamshire Hospital
The trust should ensure policies are reviewed regularly to reflect best practice and national guidance.
Should Do
Royal Cornwall Hospital
The serviceshouldensurecleardocumentationandguidanceisavailabletostaffregardingmidwifeexemptionandpatientgroupdirectivemedicine.
Should Do
Rochdale Infirmary
The trust must ensure it aligns relevant policies and procedures to reduce unwarranted variation in clinical practice, and that policies are up to date.
Must Do
Rochdale Infirmary
The trust must ensure it aligns relevant policies and procedures to reduce unwarranted variation in clinical practice, and that policies are up to date.
Must Do
Princess Royal Hospital
The trust must ensure that guidance documents have been reviewed and are up to date.
Must Do
Princess Royal Hospital
The trust must ensure that all guidance documents relating to medicines management are up to date.
Must Do
Pilgrim Hospital
The trust should ensure clinical pathways and policies are updated in line with national guidance.
Should Do
Northern General Hospital
The trust should ensure policies are reviewed regularly to reflect best practice and national guidance.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatallclinicalguidanceiscurrent.
Must Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatallpoliciesarereviewedwithinthereviewperiodsetoutinthepolicy.
Should Do
Lister Hospital
The service must ensure their policies are the most up to date version and reviewed within the timeframes stated within the policy.
Must Do
King George Hospital
The service should update their standard operating procedures for clinical areas such as RAFT and SDEC to include all areas in the department where care is being provided.
Should Do
Kettering General Hospital
The servicemust ensure there is a robust process in place to effectively review and update policies in line with national guidance.
Must Do
Jessop Wing
The trust should ensure policies are reviewed regularly to reflect best practice and national guidance.
Should Do
Fleetwood Hospital
The trust should ensure the trust updates the guidance on resuscitation trollies.
Should Do
Fleetwood Hospital
The trust should ensure that clinical pathways and protocols used within the department are in date and follow best practice guidance.
Should Do
Fleetwood Hospital
The trust must ensure there are effective processes to review and update policies and guidelines based on national guidance and evidence based practice.
Must Do
Ellesmere Port Hospital
The trust must ensure that policies and procedures are reviewed and follow national guidance.
Must Do
Edgware Community Hospital
The service should ensure references to policies and guidelines were up to date and in line with national guidelines.
Should Do
Doncaster Royal Infirmary
The trust should ensure a standard operating procedure is developed for the management of Fentanyl use as bolus doses.
Should Do
Doncaster Royal Infirmary
The trust should ensure written revalidation guidance is in place for staff to follow.
Should Do
Doncaster Royal Infirmary
The trust should ensure that all policies are reviewed within the review period set out in the policy.
Should Do
Doncaster Royal Infirmary
The trust should ensure a standard operating procedure is available for staff to refer to when fentanyl is drawn up by staff.
Should Do
Doncaster Royal Infirmary
The trust should consider a standard operating procedure (SOP) for patients on the ambulatory pathway with clear guidance to follow.
Should Do
Doncaster Royal Infirmary
The trust must ensure that all clinical guidance is current.
Must Do
Diana Princess of Wales Hospital
The trust should ensure all key policies and guidance documents are up to date.
Should Do
Diana Princess of Wales Hospital
The trust should ensure all key policies and guidance documents are up to date.
Should Do
Derriford Hospital
The service should consider reviewing guidelines more frequently in order to maintain contemporaneous with best evidence-based practice.
Should Do
Cumberland Infirmary
The trust should ensure that its alcohol withdrawal policy is reviewed and updated accordingly in a timely manner. Regulation 17(2)(b).
Should Do
Cumberland Infirmary
The trust should ensure that its alcohol withdrawal policy is reviewed and updated accordingly in a timely manner. Regulation 17(2)(b).
Should Do
Castle Hill Hospital
The service should ensure that version-controlled documents are reviewed in line with service policy and national guidance.
Should Do
ICIBI immigration recommendations(9)
An inspection of Border Force practice and procedures in relation to firearms …
Ensure that all national Border Force firearms policy and guidance documents have a clearly defined owner, are subject to regular time-bound reviews and are readily available to operational frontline staff.
An inspection of General Maritime (October 2024 – February 2025)
Update ‘General Maritime’ guidance in line with the revised definition of GM, roles and responsibilities, and record-keeping requirements, ensuring that it is subject to regular reviews to remain up-to-date.
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 8 Review operational guidance in relation to entry clearance and Temporary Admission and provide a steer (with examples) to Border Force officers at the immigration controls on how to …
An inspection of the Border Force intelligence functions at the Humber ports …
Review the policy, process and guidance for the management and dissemination of intelligence to ensure:clear ownership of new intelligence to remove time consuming deconfliction enquiries and prevent duplication of effortagency …
An inspection of General Maritime (October 2024 – February 2025)
Review Border Force’s working definition of general maritime (GM), ensuring that all Border Force staff, Home Office colleagues, partner agencies and other stakeholders, understand what is included and what is …
An inspection of Border Force’s fast parcels operations (May–July 2023)
Review the Border Force Operating Mandate in order to refresh the direction to BF.
An inspection of General Maritime (October 2024 – February 2025)
Relaunch Operation Tipson, setting a date for completion of the initial mapping of all general maritime locations of no later than 31 December 2026, and tasking the Field Intelligence Officer …
An inspection of General Maritime (October 2024 – February 2025)
Empower the Maritime Director to set the minimum standards required of Border Force regions and commands, and of Home Office Intelligence (in conjunction with the Director HOI), when conducting general …
An inspection of Border Force operations at Stansted Airport
Recommendation 8 Review operational guidance in relation to entry clearance and Temporary Admission and provide a steer (with examples) to Border Force officers at the immigration controls on how to …
PPO death in custody recommendations(10)
The Governor
The Governor should ensure that all managers understand the definition of Special Accommodation and the required protective measures set out in PSO 1700.
The Governor
The Governor should ensure that all staff are given clear guidance about and understand the circumstances in which resuscitation is inappropriate in line with European Resuscitation Council guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff are aware of the signs of rigor mortis; and fully understand the circumstances in which they should not start, or continue resuscitation, in line with European Resuscitation Council Guidelines.
NHS England and the Welsh Government
NHS England and the Welsh Government should develop national guidance for establishments to develop local standard operating procedures for healthcare input in the use of force/restraints risk assessments. This guidance should also include roles & responsibilities of healthcare during and …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are aware of PSI 03/2013 and radio a medical emergency code in an emergency situation, including in the event of a fire.
The Operational Security Group Director at HMPPS
The Operational Security Group Director at HMPPS should monitor compliance with policy on the use of restraints during hospital escorts (for inpatient and outpatient appointments), including at HMP Littlehey, and discuss the findings with the Ombudsman.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that Early Release on Compassionate Grounds applications are completed in line with Policy Framework by: • ensuring that prison staff request a report from Probation staff for the application; and • …
The Operational Security Group Director at HMPPS
The Operational Security Group Director at HMPPS should monitor compliance with policy on the use of restraints during hospital escorts (for inpatient and outpatient appointments), including at HMP Oakwood, and discuss the findings with the Ombudsman.
The Director of HMP Parc
The Director should consider carefully and set out what further action he intends to take in the case of omissions in unlock procedures.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at high risk of complications from COVID-19 in line with national guidance. Key actions and decisions should be fully documented in prisoners’ medical and personal records.
IOPC learning recommendations(76)— showing 50 strongest matches
Police response to an abandoned emergency call – Cleveland Police, March 2020
The IOPC recommends that Cleveland Police policy and guidance documents are relevant and up to date, ensuring standard roles and responsibility policy documents for all supervision and staff working within the control room are in place, fit for purpose and …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that a review of PACE Code C Annex H is undertaken in relation to the guidance on dealing with detainees withdrawing from drugs and alcohol, including withdrawal symptoms masking other serious problems. The review should include consideration …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) and College of Policing work together to review and update guidance on the use of the Flexible Lift and Carry System (FLACS) following completion of the medical testing recommended in …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should review the processes through which the Flexible Lift and Carry System (FLACS) and other operational equipment are introduced and reviewed and ensure these are aligned with the most recent …
National recommendations - National Police Chiefs Council, September 2020
The IOPC recommends that national guidance be amended/updated to state that prior to firearms operations, where timing allows (e.g. pre-planned operations) and where doing so would not present any issues regarding safety and security, an incident log should be created …
Recommendations - West Midlands Police, June 2021
The IOPC recommends that West Midlands Police create a policy on handling concern for welfare calls. This policy should cover the responsibility for informing third parties and should provide guidance for officers and staff members dealing with an enquiry relating …
Recommendations - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police should amend missing persons policy to expand on Chapter 9 “Concern for Welfare or Safe and Well” and the missing persons flow chart. This follows an IOPC investigation where the incident type was …
Recommendations - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police should take steps to formalise the escalation and vulnerability doctrines (as set out in the force document “HMIC Observations and action taken following September 2017 Inspection”) into a compulsory policy and take step …
Recommendation - Derbyshire Constabulary, April 2026
The IOPC recommends that Derbyshire Constabulary should review and update its operational guidance and officer training on responding to suicide-related incidents to ensure officers clearly understand the legal powers available to them to remove items that pose an immediate risk …
Recommendations - Thames Valley Police, December 2024
The IOPC recommends that Thames Valley Police (TVP) ensure that its training and guidance on restraint and positional asphyxia clearly states the role and responsibilities of the safety officer. This includes when a safety officer should be used, the safety …
Recommendations - Thames Valley Police, December 2024
The IOPC recommends that Thames Valley Police (TVP) review its training material on handcuffing from prone (subject lying on their front) and the use of ground pin. The review should consider whether training is sufficiently clear regarding: - How a …
Recommendations - Metropolitan Police Service, January 2026
The IOPC recommends that the Metropolitan Police Service (MPS) reviews and updates its call handling policy to ensure its policy complies with the National Standards for Incident Recording (NSIR). This recommendation has arisen as a result of a review of …
Recommendations - Sussex Police, March 2020
The IOPC recommends Sussex Police should review ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)' policy with specific reference to the below; The ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ appears to be …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police reviews its Sudden and Unexpected Deaths Procedure, Unexpected Child Death FIM Guide, and Form F13 Report of Sudden Death (notes of guidance) to ensure they are consistent with one another in respect of …
Teenager took his own life after calling police for assistance – Kent …
The IOPC recommends that Kent Police provide clarity within their policies and guidance in relation to the grading of and dispatch to incidents where a ‘threat to life’ has been received by the control room, but no exact location is …
Recommendations - South Wales Police, July 2022
The IOPC recommends the NPCC (as holders of the national portfolio for custody and detention) provide guidance to all police forces highlighting: The Prisoner Escort Custody Service (PECS) is a stand-alone system which does not interface with any police systems. …
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) issues an accessible guidance document to Emergency Response Team (ERT) Officers outlining the expectations and processes involved when handing a case over to the My Investigation Support Team (MIST). This should …
Recommendations - Nottinghamshire Police, February 2026
The IOPC recommends that Nottinghamshire Police should review and amend policy documents ‘PS260 – Suicide Prevention and Risk Management of Suspects’ and ‘PD485 – Dealing with Indecent Images of Children and Extreme pornography’ to include suspects who are under investigation …
Recommendations - Sussex Police, November 2019
There was a lengthy delay in resourcing a request for a welfare check that was graded Grade 2 (expected response time 1 hour). During the investigation it became apparent there was no single local policy that provided guidance on how …
Recommendations - Sussex Police, March 2020
The Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts …
Police response to a domestic incident - Essex Police, September 2020
The IOPC recommends that Essex Police should review the quality and effectiveness of its initial and refresher domestic abuse training for frontline officers with specific reference to: - the responsibility of officers to take positive action (including arrest of perpetrator) …
Recommendations - Kent Police, November 2020
The IOPC recommends that Kent Police provides their operational employees with clarity on the different definitions of the term ‘vulnerable.’ There are two strands to this recommendation: - Kent Police to ensure officers and staff sufficiently understand how to assess …
Recommendations - Northamptonshire Police, March 2021
The IOPC recommends that Northamptonshire Police should take steps to assure itself that appropriate systems are in place to ensure that custody staff adhere to their responsibility, in accordance with Paragraphs 8.8 and 8.10 of PACE Code C, to record …
Recommendation - Sussex Police, April 2021
The IOPC recommends that Sussex Police devise specific guidance on the disposal options to be made available when dealing with low level driving collisions committed by any officer on duty but not answering an emergency. All Roads Policing Investigators and …
Recommendations - Sussex Police, April 2021
The IOPC recommends that Sussex Police should review their policy in relation to the use of a spit guard after incapacitant spray has been used. Any detainee should be regularly reassessed to ensure continued use of a spit guard is …
Recommendations - Sussex Police, April 2021
The IOPC recommends that Sussex Police review their policy in relation to cell extraction to ensure it provides guidance on the continued use of, and the removal of, a spit guard during the technique. The policy should define responsibility for …
Recommendation - South Wales Police, October 2020
The IOPC recommends that South Wales Police (SWP) amends the first aid training provided to front line officers to ensure all officers and staff receive training regarding managing a casualty with a head injury. In the interim, SWP should take …
Recommendation - Merseyside Police, March 2021
The IOPC recommends that Merseyside Police should review and update their body worn video policy so that it better reflects national guidance. This follows an IOPC review where at least three officers were present during an arrest but there is, …
Recommendations - Metropolitan Police Service, March 2021
The IOPC recommend that the Metropolitan Police Service (MPS) draft and implement a new standard operating procedure (SOP), or amend any relevant existing SOP, to provide officers with clear guidance as to roles and responsibilities relating to incident management, outside …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police takes steps to ensure all relevant officers and staff, included but not limited to: Gold, Silver, and Bronze Commanders and Force Incident Managers, receive training on the following policies and how they interact …
Stop and search - Bedfordshire Police, October 2018
The IOPC recommends that Bedfordshire Police amend their stop and search record slips to include a question about whether force has been used. The slips should also state where information about the type of force will be recorded. During this …
Recommendation - Metropolitan Police Service, April 2020
The IOPC recommends that the MPS should take any necessary steps to ensure that officers are aware of what actions can be taken when criminal investigations or proceedings end, but the victim still requires safeguarding. Such steps might include producing …
Recommendation - Essex Police, May 2020
The IOPC recommends that Essex Police review its relevant policies and procedures (including the Missing Persons Procedures) to ensure that there is a process for the duty sergeant to be notified when officers have been tasked to undertake actions on …
Recommendations - West Yorkshire Police, June 2020
The IOPC recommends that as a part of the ongoing West Yorkshire Police (WYP) review of its missing from home policy, WYP should stipulate which supervisor has command and control of a missing from home report. That officer should record …
Recommendations - West Yorkshire Police, June 2020
The IOPC recommends that as a part of the ongoing West Yorkshire Police (WYP) review of its missing from home policy, WYP should consider directing that once an officer has taken a missing from home report they should liaise with …
Recommendations - West Yorkshire Police, June 2020
The IOPC recommends that as a part of the ongoing West Yorkshire Police (WYP) review of its missing from home policy, WYP should consider clearly defining which officer has the responsibility of conducting research of information systems (eg. Police National …
Recommendation - Sussex Police, September 2020
The IOPC recommends that Sussex Police should change its policy to state that all non-covert arrest enquiries will have at least one officer wearing a body worn camera in attendance. During the course of this investigation it transpired that plain …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police consider updating force policy to robustly cover checking cells specifically for the purpose of detainee safety. Force policy should be clearly communicated to custody staff with training and oversight to ensure that cell checking …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police consider a review of the suitability and effectiveness of metal detectors used in their custody suites. It should be clarified what types of item the metal detectors currently being used can/cannot identify and ensure …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This could be reinforced by additional …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends the MPS should conduct a review of the staffing levels at the Directorate of Professional Standards (DPS) to satisfy themselves that they are adequate to meet the needs of that department. This report makes repeated reference to …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends that the MPS should consider putting policy in place that outlines the minimum standards required in Death and Serious Injury (DSI), complaint and conduct investigations. This policy should address the following requirements: - The legal obligation under …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends the MPS should create a role profile for Directorate of Professional Standards (DPS) investigators and DPS IOPC Single Point of Contacts (SPoC), outlining the requirements of the role and the role holder’s key responsibilities. The MPS should …
Recommendations - Metropolitan Police Service, June 2020
The MPS should amend their Death and Serious Injury (DSI) investigation report template to specifically reference the three following questions: - What evidence is available regarding the nature and extent of police contact with [X] prior to his/her death/serious injury? …
Recommendations - Metropolitan Police Service, June 2020
The MPS should treat daybooks as controlled stationery across the whole force. Recognising that they contain relevant material to criminal, conduct and Death or Serious Injury investigations the movements and continuity of these books should be audited, and they should …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends that the MPS Should consider providing role specific training to all of its professional standards investigators. It is recommended that this training addresses the following requirements: - The legal obligation under s21 Police Reform Act 2002 of …
Recommendation - Greater Manchester Police, September 2020
The IOPC recommends that the College of Policing amend the custody and detention, detainee care section of the Authorised Professional Practice (APP) to make it clear what they expect officers to do when a detainee cannot be roused in accordance …
Police contact with a woman before her death and a subsequent complaint …
The IOPC recommends that Cleveland Police should implement a formal process for feeding back relevant information from Multi Agency Risk Assessment Conference (MARAC) meetings to staff within the Protecting Vulnerable People (PVP) unit. During the misconduct interviews for two officers …
Recommendation - Metropolitan Police Service, November 2020
The IOPC recommends that the Metropolitan Police Service (MPS) should review the spinal injuries topic within its Emergency Life Support (ELS) training for police officers to ensure that scenarios and examples used do not solely focus on motorcycle accidents and …
Recommendation - Metropolitan Police Service, October 2020
The IOPC recommends that the Metropolitan Police custody policy (Risk Management, section D5) should be amended to include specific reference to the Royal College of Emergency Medicine (RCEM) guidance on the Management of Suspected Internal Drug Traffickers (2020) which advises …
IMB individual recommendations(2)
National patient safety alerts(1)
Health investigations(144)
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
All parties should understand the context in which conditions are attached to restricted patients’ discharge by tribunals, or are added by the Home Office. The Home Office should issue guidance on the standing of the conditions when there may be no sanctions in the event of breach.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 6
Home Office Guidelines should be brought up-to-date urgently. There should be a single document in a form where supplements and amendments can be easily inserted.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
The Home Office and the DofH in conjunction with the relevant professional bodies should formulate guidelines for the testing for substance misuse with restricted patients.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 3
All parties should understand the context in which conditions are attached to restricted patients’ discharge by tribunals, or are added to by the Home Office. The Home Office should issue guidance on the standing of conditions when there may be no sanctions in the event of breach.
south_east
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.3.4
The current Memorandum of Procedure on Restricted Patients should be reviewed in the light of the recommendations of this Inquiry.
scotland
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.2.1
The Social Work Department must review its operational policies and procedures, in respect of its supervision of conditionally discharged patients; it should involve all relevant sections of the Department in the review. It should carry out the review in consultation with the Health Board and the SEHD Mental Health Division.
scotland
Independent investigation: Simon Breed, Wood Green (2004) — Rec R12
The 2008 CPA policy is reviewed and amended to take into account the problems that we have identified in the PT case and to ensure that policy is compatible with all other relevant trust policies and protocols.
london
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.18.8
If implemented, these proposals would require the amendment of the NHS national guidance governing independent investigations. A review of this guidance would be timely and appropriate.
south_west
Independent investigation: John Stevens, Woking (2001) — Rec 13
We recommend that the North West Surrey Mental Health Partnership Trust develops an operational policy to take account of the role, function, resource allocation, management arrangements and scope of the Mental Health Act Administration Service.
south_east
Independent investigation: Jenny Morrison (s/w), Balham,S London (1998) — Rec 6
The Department of Health considers extending the guidance referred to above to ensure that adequate reference is made to the application of the Care Programme Approach as it applies to service users in residential care settings.
london
Independent investigation: Amina Ali, Sheffield (2004) — Rec 4
The Operational Policy for the CNS Service needs to be updated so that it becomes a valuable and practical document for staff. During the investigation process the Investigation Team identified that the current Operational Policy for the Continuing Needs Service is not fit for purpose. Given the central importance of …
north_east_yorkshire
An independent investigation into the care and treatment of mental … — Rec 2b
The Trust and NHS Manchester CCG must develop and agree guidance for GPs on the administration of clozapine and the limited function of blood tests for titration.
Greater Manchester Mental Health NHS Foundation Trust
north_west
An independent investigation into the care and treatment of mental … — Rec 2a
The Trust must provide clear guidelines for risk assessment and care planning for the titration of clozapine in the community.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 7
The service manager for the CRHT recognises that their current service profile document is out of step with the way the CRHT currently operates. He has made a commitment to updating this service profile, incorporating the feedback contained in this report by the end of November 2008.
north_east_yorkshire
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 1
How the Trust treats third party information, especially where it relates to the potential for risk behaviour in a service user, needs to be debated within the Trust’s governance and risk management groups. It is not acceptable for staff to be expected to use their individual judgment on such an …
north_east_yorkshire
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 5
TEWV must review the TEWV CPA policy to ensure that overdue depot medication is communicated effectively in referral procedures and correspondence, e.g. by ‘phone.
north_east_yorkshire
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 2
TEWV must review the EIPT operational policy to set out agreed methods and expectations around multidisciplinary working, to ensure that senior medical staff are involved appropriately in discussions about patients where staff have concerns, and at least annually, where patients are receiving antipsychotic medication.
north_east_yorkshire
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 1
TEWV must develop an agreed set of local policies and procedures to be regularly reviewed by key strategic partners in line with the November 2016 NICE8 guidance on coexisting severe mental illness and substance misuse: community health and social care services.
north_east_yorkshire
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station … — Rec 6
The Trust needs to review the CMHT Operational Policy to ensure that all the contributory factors noted in this report have been addressed, in particular the role and function of duty workers and the interface between the OPAand dutysystems.
london
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 3
The Trust must ensure that policy guidance includes the management of requests by family and other professionals, when concerns are expressed about a person’s mental health, that the policy is in line with best practice, and that appropriate training is provided to relevant staff.
south_west
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 2
The Trust (or the Council if MHA AMHP assessments are no longer covered by a Section 75 agreement) must ensure that requests from NRs are considered and responded to appropriately. An evaluation of current practice and policy is advised to ensure it is clear about how to manage NR requests …
south_west
Independent investigation: Sally Poynton, Crowlas (2021) — Rec 1
The Trust must ensure that relevant organisational policies are aligned to the MHA and the MHA Code of Practice. The Trust must also provide training on the role and rights of the NR to frontline staff to ensure that correct advice is given to NRs.
south_west
Independent investigation: Peter Hartley, Keighley (2001) — Rec 6.2.6
Operational policy for Community Drug & Alcohol Teams needs reviewing and updating as the policy given to Panel was dated October 1994.
north_east_yorkshire
Independent investigation: Michael Martin, Almondsbury, (1999) — Rec 5
No social services and health jointly agreed guidelines on the operation of CPA existed between 1996 until the homicide in May 1999. Old documentation had not been revised after unitary authorities replaced Avon Social Services. This was unsatisfactory and confusing.
south_west
Independent investigation: Michael Green, Nottingham (2005) — Rec R4
The trust should ensure policies and procedures are updated in a timely way when new guidance is issued.
midlands
Independent investigation: John Redhead, Potters Bar (2007) — Rec 10
The Trust should review the processes in place for responding to service users and carers reporting crisis situations to the CMHT, and develop guidance and policy for clinicians detailing the appropriate care pathways that should be used to ensure risk is assessed and an appropriate response is made.
east_of_england
Independent investigation: John McGrath, Stapleford, Nottingham (2009) — Rec 1
As a corporately delivered service, all AO Teams in Nottinghamshire Healthcare NHS Trust should have a consistency in approach across all of its core systems and processes, including the zoning system. Nottinghamshire Healthcare NHS Trust must ensure that all of its AO teams work to a common operational policy, with …
midlands
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 6
The Trust should rewrite the CPA policy and guidelines.
london
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 5
The Trust should have a policy dealing with detained patients who are absent without leave which complies with the Act Code of Practice.
london
Independent investigation: Jan Jensen, Hassocks (2012) — Rec R2
The trust should further review the AWOL/missing persons policy in conjunction with Sussex Police and should ensure that staff in both organisations understand its operation.
south_east
Report of a review in respect of: Mr D and … — Rec 1.18
This policy should be reviewed taking into account that a non-shockable rhythm could include an agonal rhythm or pulseless electrical activity where resuscitation would be appropriate. Consideration should be given to removing point i) from the list to avoid confusion as asystole, as covered in point v) is the only …
wales
Report of a review in respect of: Mr D and … — Rec 1.13
The WAST Lone Worker policy needs to be reviewed to ensure that patient care is not compromised by withholding solo resources. The use of meeting points and methods of liaising with the police in order to ensure the safety of the crew should be addressed.
wales
Report of a review in respect of: Mr D and … — Rec 1.12
Prior to the arrival of the ambulance crew, first aid was not given to Father Paul. Bystander resuscitation should be encouraged for all calls where patients are unconscious and not breathing, unless the patient is unequivocally deceased as defined by the WAST ROLE/DNAR policy.
wales
Report of a review in respect of: Mr D and … — Rec 1.10
In relation to the repeated requests for Mrs Bennett to check on her husband, given that the assailant was still present at the scene when Father Paul’s wife made the 999 call, we believe that control room operator should apply the same standards of scene safety to callers as for …
wales
Independent investigation: Faridon Alizada, Erith (2008) — Rec R2
The trust should include within its guidance on services for people with personality disorder how partnership working with families should be carried out.
london
Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003) — Rec 16
The Trust should examine all its policies and procedures to ensure that they are up to date, and establish a process for monitoring and the regular auditing of their implementation. Where reviews of policies and procedures are overdue or necessary they should be completed as soon as possible. A system …
london
Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003) — Rec 12
The opportunity should be taken to refine the John Meyer Ward Operational Policy, building on the good work to date, in preparation for the move to the new purpose-built PICU.
london
Independent investigation: Ernie Meads, Edmonton, Wood Green, N London (2004) — Rec 5
That Haringey Teaching Primary Care Trust and Barnet, Enfield and Haringey Mental Health Trust review their Serious Untoward Incident Policy in the light of the findings of this report to ensure that the spirit of the National Patient Safety Agency guidance Being Open is fully met.
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 16
Staff should be given clear guidance in the form of an escalation policy on what to do if a patient continues to refuse to give blood or urine samples. (II/DB)
london
Independent investigation: Eric Daggers, Croydon (2005) — Rec 3
Local guidance should be provided on the long-term management of people with anti-social personality disorder. (DB)
london
The trust response to the Niche Independent Inquiry into the … — Rec 9
The Trust should develop good practice guidance on leave of absence under section 17 of the Mental Health Act, which should, amongst other elements, require responsible clinicians to set out clear criteria and conditions for such leave.
south_west
NHS England subsequently published a quality assurance review to assess … — Rec New Recommendation 1
Update this SOP (which has expired) and consider the impact of the PSIRF in doing so.
south_west
Independent investigation into the care and treatment of Mr Z: … — Rec 5
That the Trust’s risk assessment guidance will be updated to include an assessment of risk in light of complex interactions between intrinsic and extrinsic factors and the need to recognise risks that arise as a result of the proposed therapeutic interventions. These revisions need to be made in accordance with: …
Manchester Mental Health and Social Care NHS Trust
north_west
Independent investigation into the care and treatment of Mr Z: … — Rec 10
The Trust must revise all policy documentation in keeping with the findings of this Investigation report and as set out in recommendations 1-9 above. All policy documentation should be subject to review and audit for both compliance and effectiveness as part of the Trust audit cycle.
Manchester Mental Health and Social Care NHS Trust
north_west
Independent investigation into the care and treatment of Mr D … — Rec 4
The Trust should develop guidance detailing what staff should do in response to service users making verbal threats against other service users. This should include who should be informed and the documentation of agreed actions.
Cambridgeshire and Peterborough NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Mr D … — Rec 3
The Trust must review its Managing Violence and Aggression Against Staff Policy to clarify what actions staff should take in response to a physical assault by a service user. The review should address the ambiguity in relation to whether the police should be contacted in response to an assault, the …
Cambridgeshire and Peterborough NHS Foundation Trust
east_of_england
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 65
• NHS England and NHS Improvement should ensure that guidance to ROs is up to date and a final version is in force to include the 2013 RO regulation amendments and learning since the role was introduced. • Regional Medical Directors should use this investigation as a case study to …
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Mr … — Rec 7
The Trust must ensure that the new guidance for documenting MAPPA discussions is included in the appropriate policy.
south_east
An independent investigation into the care and treatment of mental … — Rec 3
The Trust AWOL policy should be amended to ensure that any decision to discharge an AWOL patient in their absence is explicitly risk assessed, supported by a detailed decision making tool, and reported on centrally to ensure practice is monitored.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
An independent inquiry into the care and treatment of Ms … — Rec 8
The Management of Unregistered Patients protocol to be reviewed and amended with further guidance included where required. This protocol should include a method for ensuring registered GP, any temporary registrations and the name of the last GP seen are sought from patients and or their relatives.
south_east
Scottish Fatal Accident Inquiries(18)
Neil William Bremner
Nonetheless, it is clear from the evidence of both Mr Marr and his colleague Mr Radcliffe that the Health and Safety Executive might profitably consider rewording the information sheet so as to achieve the effect suggested by Mr Main and I recommend that they should so consider the matter. They might also wish to consider whether there are any reasonable …
Mary MacAuley
A review of the procedure for the categorisation of calls by the DACS alarm service may prevent other deaths in the future.
Jan 2012
Ann Marie Merrigan or Copeland, Niamh Maria Copeland and Ciara Jenny Copeland
RECOMMENDS that manufacturers of hydraulic hoses for mobile cranes give further consideration as to whether or not, in addition to regular inspection and maintenance of hoses, there should be issued guidance in relation to the service life of hydraulic hoses; (B) RECOMMENDS that the report forms for thorough examination under the LOLER regulations be revised to include clear warnings that …
Jan 2012
Terence Michael Griffin
It does occur to me thought that there was merit in the suggestion that the guidance issued to doctors on this issue might be made more directive. If the guidance was to the effect that a doctor in the situation under discussion here had to advise the patient that he must not drive and that the patient was obliged to …
Sep 2013
Super Puma
(a) The joint working group of the European Aviation Safety Agency (“EASA”), the Federal Aviation Administration, the rotocraft industry and the Technical Oversight Group for Ageing Aircraft has considered a proposal by EASA to introduce improvements in the ability to avoid catastrophic failures of primary structures, including rotor transmission components, of helicopters. EASA intends to incorporate this amendment into its …
Mar 2014
Giovanni Cocozza
(1) Aberdeen Royal Infirmary Radiology Department should review its procedures so as to ensure that there are in place clear and uniform protocols concerning the way in which requests for imaging which are not unconditionally accepted are dealt with. In particular, it would be desirable if possible that where an alternative form of imaging is proposed, there be discussion with …
Jul 2014
Andrew Logan
(b) that there is a need to take steps to ensure that all staff at the Ambulance Control Centre of Scottish Ambulance Centre are familiar with, and understand the importance of complying with, the protocol in force in respect of procedure when an urgent call will not be dealt with within the required timescale; It seems to me, therefore, that …
Sep 2015
Douglas Brian Gordon
In view of findings (xvi), (xix) and (xx) the Sheriff respectfully recommends that consideration be given by the Secretary of State for Transport’s Honorary Medical Advisory Panel on driving and disorders of the cardiovascular system and by the DVLA to instituting a review of the wording of the DVLA’s latest guidance “Assessing fitness to drive: a guide for medical professionals”, …
Sep 2016
Ian John Leitch Black
I therefore make no recommendations about this, but there may be some merit in steps being taken by the Health Board to clarify good practice.
Dec 2016
Scott MacAlister
That the current recommendation at section 3.17 of the Code of Practice for the Safety of Small Fishing Vessels MSN 1871(F) - that all crew working on the open decks of fishing vessels at sea or in categorized waters wear Personal Flotation Devices (i.e. lifejackets or buoyancy aids) - be replaced with a mandatory requirement to that effect.
Aug 2018
Graham Stewart Shaw
of the said Act, another fact which is relevant to the circumstances of the death of the deceased is that a revision of the “Safe Stop” section of the Health and Safety Executive document “Working safely with Agricultural Machinery” should be undertaken to remove any ambiguity as to the circumstances in which “Safe Stop” procedure should be adopted by extending …
Oct 2019
Gordon Stewart Lennon
[58] Because of that, I agree with the submission on behalf of the family that a recommendation be made that the police and Procurator Fiscal should review their policy on the investigation of vehicle collisions which do not occur on the public highway.
Feb 2012
Judith Laing
The need for a review of procedure at Inverclyde Royal Hospital on how amended reports/results/findings are introduced into a patient’s medical records, how the existence of an amended report/result/finding or opinion is highlighted in the patient’s medical records, and how any amendments are brought to the immediate attention of those treating a patient. I consider there should be a system …
Jan 2013
Raymond Hector Davidson
a. Consideration is given to ensuring that all fishing vessels submit annual Risk Assessments to MCA under The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997 b. Consideration is given to revising the Code of Practice for the Safety of Small Fishing Vessels to the effect that:- i. The wearing of lifejackets at all times is …
Nov 2014
Gary Daniel Forbes
(i) That the Maritime and Coastguard Agency give consideration to amending The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997 so that they apply to share fishermen, thereby requiring all persons on board fishing vessels to wear personal flotation devices or lifejackets when working on deck. (ii) That the Maritime and Coastguard Agency give consideration to …
Aug 2016
Ciaran James Williamson
1. I recommend that the Scottish Government issue separate guidance on memorial safety in cemeteries for use by local authorities throughout Scotland. Such guidance should include a category of advice on how to inspect large, traditional monuments such as the Ross memorial, as distinct from lawn memorials and other smaller structures. Given the potential danger posed by large leaning memorials, …
Jan 2018
Steven Allen
I believe that it makes good practice for the dive to be regarded as terminated once the diver is physically and safely on board the diving vessel. I understand that this is now the practice. Video recording should only be terminated and the diver recovery only equipment put away when the diver is physically and safely on board the diving …
Dec 2012
Jay Alexander Boyd
The sheriff, in terms of section 26(1)(b) of the Act, and having regard to the matters mentioned in section 26(4) of the Act, recommends that: (1) The Scottish Prison Service should review the Standard Operation Procedure: Prisoner Numbers Checks - Completing & Recording (reference number SOP 403) for HMP Glenochil to align the language contained within it to that contained …
May 2024
Detention investigations(2)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 37
IND produce a security manual for the detention estate.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 36
the operating standards be completed and rolled out across the estate as soon as possible and to a published timetable.
Immigration Detention
Independent reviews(50)
Youth Justice Board Review — Rec 6
MOJ’s YJPU, in consultation with the YJB, should take this opportunity to amend legislation to reflect the functions of the YJB as they stand and formally transfer those relating to custody to YCS.
Justice & Legal
Owens Review — Rec 9
The Ministry of Justice and HMPPS to review the policy on Release License. The aim should not be to determine retrospectively which interpretation was 'correct,' but to recognise that frontline staff cannot be expected to interpret contradictory or opaque policies, especially where the stakes are high. Operational staff require clear-cut, …
Justice & Legal
Owens Review — Rec 6
Introduce a clear process at operational level by which staff can escalate conflicting use of 'Not for Release' markers before a discharge or release is authorised.
Justice & Legal
Owens Review — Rec 5
HMPPS should clarify at an operational level when 'Not for Release Markers' should be used and mandate the checking of all 'Not for Release' markers during release and discharge processes.
Justice & Legal
Owens Review — Rec 4
That HMPPS clarify operational guidance on what a high-profile alert means, when it should be used, what should happen as a result during the release process and/or other prisoner movements and use, triggering a clear sequence of events.
Justice & Legal
Cunliffe Water Commission — Rec 9
Recommendation 9: The UK and Welsh governments should update and reform the UWWTR 1994 to deliver better outcomes and a more sustainable approach to drainage and wastewater management. This should involve reporting on whether an Extended Producer Responsibility scheme is needed for the water sector to fund necessary improvements.
Other
Cunliffe Water Commission — Rec 8
Recommendation 8: The UK and Welsh governments should review the current water legislative framework and amend it accordingly.
Other
Corry Defra Regulation Review — Rec 16
Defra should rapidly review and rewrite its existing catalogue of compliance guidance to ensure it is fit for purpose, removing any duplication, ambiguity and inconsistency. The aim of the review should be a streamlined, clear and up to date catalogue, signposted for each sector so that it is easy to …
Other
Corry Defra Regulation Review — Rec 14
The recommended programme of reform for specific regulations should also assess instances of overlap and duplication in the application of regulations, with the aim of streamlining priority areas, for example in the marine environment, where multiple regulators are involved in assessing the same applications for port infrastructure. Both the regulations …
Other
Corry Defra Regulation Review — Rec 13
The work to update the Environmental Permitting (England and Wales) Regulations 2016 to allow regulators more flexibility to take sensible, risk-based decisions should be accelerated due to the important role it plays in supporting net-zero and circular economy priorities (e.g. facilitating the development of low carbon industrial infrastructure, and for …
Other
Corry Defra Regulation Review — Rec 12
Defra should swiftly develop plans to reform slurry application and storage to help address diffuse water pollution from agricultural sources. This is likely to involve changing the Farming Rules for Water and wider regulations relating to slurry application and storage. This should aim for a single set of regulations which …
Other
Corry Defra Regulation Review — Rec 11
Scope a rolling programme of reform for specific regulations, being clear what can be done rapidly, where the quickest wins are and what will take longer. This review suggests areas of focus, but the department needs to work rapidly to scope them and establish the programme. Pending fuller scoping, early …
Other
Corry Defra Regulation Review — Rec 4
Consolidate the statutory duties, principles and codes of Defra regulators to a core set, reflecting the Government's priorities and helping to provide discretion, e.g. a duty to deliver on/consider climate change/net zero. This will address the increase in regulator-specific and regulator-generic legal obligations and resulting 'regulatory overload' which has emerged …
Other
Pickles Electoral Fraud Review — Rec R9
Clearer guidance should be provided on the circumstances in which Electoral Registration Officers should seek further evidence as to an applicant's address.
Other
Pickles Electoral Fraud Review — Rec R8
The Government should consider the options for electors to have to produce personal identification before voting at polling stations. There is no need to be over elaborate; measures should enhance public confidence and be proportional. A driving licence, passport or utility bills would not seem unreasonable to establish identity. The …
Other
Pickles Electoral Fraud Review — Rec R7
Completed postal ballot packs should only be handed in at a polling station by the voter or a family member / designated carer acting on their behalf – a limit of two should be applied for any one person handing in completed ballots and require an explanation as to why …
Other
Pickles Electoral Fraud Review — Rec R6
Guidance should be produced on layout of polling stations and actions to minimise scope for people to be able to take a ballot paper out of a polling station.
Other
Williams GNM Review — Rec 3.3
Advice to senior investigating officers should be updated to reflect the explanatory statement on gross negligence manslaughter set out by the working group (1.1) and the standards for healthcare professionals providing an expert opinion or appearing as expert witnesses (2.1).
Health & Social Care
Williams GNM Review — Rec 3.1
The Chief Coroner should consider revising the guidance on gross negligence manslaughter in Law Sheet no 1 in light of the explanatory statement set out by the working group under 1.1. We expect coroners will routinely consider this guidance in assessing the facts on whether or not a referral for …
Health & Social Care
Williams GNM Review — Rec 1.2
All relevant organisations, including, if appropriate, the Director of Public Prosecutions, should produce or update guidance on gross negligence manslaughter in light of the explanatory statement set out by the working group in 1.1. This will promote a consistent understanding of where the threshold for prosecution for gross negligence manslaughter …
Health & Social Care
Winsor Review Part 2 — Rec 47
The Police Regulations 2003 should be amended to provide for the payment of financial compensation to police officers with less than full pensionable service who leave the police service by reason of compulsory severance. Forces should be empowered to offer financial compensation on the same terms as are available under …
Policing & Security
Winsor Review Part 2 — Rec 46
The Police Regulations 2003 should be amended to create a system of compulsory severance for police officers with less than full pensionable service from April 2013.
Policing & Security
Winsor Review Part 2 — Rec 38
The Police Regulations 2003 should be amended to specify the procedure for determining the circumstances in which an officer may be placed on restricted duty, the arrangements which a Chief Constable may make for officers on restricted duty, and the adjustments to the pay of such officers.
Policing & Security
Flanagan Review of Policing — Rec 23
The Home Office should urgently initiate a review of the RIPA Codes of Practice. Once initiated I see no reason why with determination and commitment from the interested parties involved such a review could not be conducted over a 3 month period.
Policing & Security
Flanagan Review of Policing — Rec 19
All existing doctrine, which includes regulations, codes of practice, operational policing manuals and practical advice on best practice in the police service, should be reviewed and consolidated so the total impact can be assessed and overlaps in individual documents removed by the end of 2008. This process should be led …
Policing & Security
Laming Review (Baby P) — Rec 50
The Department for Children, Schools and Families must provide further guidance to Local Safeguarding Children Boards on how to operate as effectively as possible following the publication of the Loughborough University research on Local Safeguarding Children Boards later this year.
Other
Löfstedt Review — Rec 2
HSE should review all its ACoPs. The initial phase of the review should be completed by June 2012 so businesses have certainty about what is planned and when changes can be anticipated.
Other
Barker Land Use Planning Review — Rec 18
There should be a rebalancing of the focus of planning on the cases that matter most, in line with the principles of risk-based regulation by: • a widening of permitted development rights for minor consents by extending the ‘impact’ principle of the Householder Development Consent Review, so that in future …
Other
Barker Land Use Planning Review — Rec 17
The Government should, as a matter of priority, work with local planning authorities and other bodies such as the Better Regulation Executive to reduce substantially the information requirements required to support planning applications. The principle should be to move towards a risk-based and proportionate approach to information requests. Action should …
Other
Barker Land Use Planning Review — Rec 15
Local planning authorities and regional planning bodies should continue to develop their development plans as expeditiously as possible to provide a clear planning framework for decisions. DCLG should urgently review the regulations and guidance behind the new plan-making system to enable the next generation of development plan documents to be …
Other
Barker Land Use Planning Review — Rec 14
There should be a substantial streamlining of national policy, delivering previous commitments. The Government should publish proposals by summer 2007. This should include consideration of the potential to remove some of the current range of Planning Policy Guidance, and where necessary replace through an expanded PPS1. Any new policy should …
Other
Barker Land Use Planning Review — Rec 13
The Government should consolidate the secondary legislation related to planning. A priority is to consolidate the General Development Procedure Order and its subsequent amendments – this should be undertaken in 2007. Streamlining the planning system National policy guidance 4.8 A second area of complexity relates to the volume of national …
Other
Barker Land Use Planning Review — Rec 4
Wider planning policy should be made more responsive to economic factors. This should include: • building on the more flexible approach to car-parking spaces for housing, by applying this less prescriptive approach to commercial development in place of the current national maximum standards per square metre of floor space; • …
Other
Barker Land Use Planning Review — Rec 3
DCLG should update its national planning policy on economic development by the end of 2007. This should include: • emphasising the critical role economic development often plays in support of wider social and environmental goals, such as regeneration; • strengthening the consideration given to economic factors in planning policy, so …
Other
Barker Land Use Planning Review — Rec 2
The Statement of General Principles should be revised to make clear that in determining planning applications, due regard should be paid to the economic, social and environmental benefits of development, such as the benefits new development can bring through low average energy consumption, alongside other material considerations. 17 ODPM Planning …
Other
Barker Land Use Planning Review — Rec 1
DCLG should revise the policy framework for decision-making, in the context of the plan-led system, to make clear that where plans are out-of-date or indeterminate applications should be approved unless there is good reason to believe the costs outweigh the benefits. One way of implementing this would be to make …
Other
Harrington WCA Review (Year 2) — Rec 11
These changes [to LiMA, based on comments from the stakeholder seminars] should be adopted, and that further changes to LiMA are considered as and when they are raised.
Employment & Work
Taylor Review — Rec 1
Government should replace the minimalistic approach to legislation with a clearer outline of the tests for employment status, setting out the key principles in primary legislation, and using secondary legislation and guidance to provide more detail.
Employment & Work
Accepted
Kerslake Review — Rec 47
The Independent Press Standards Organisation (IPSO) should review the operation of its code in the light of the experiences described by contributors to the Review and consider developing a new code specifically to cover such events
Policing & Security
Accepted
Kerslake Review — Rec 20
Operation PLATO should be reviewed and modified as deemed necessary to inform the response to any form of terrorist attack and be referred to as the Joint Operating Principles for Responding to a Terrorist Attack, regardless of whether firearms are thought to be involved
Policing & Security
Accepted
Kerslake Review — Rec 11
Whilst the Panel acknowledges that Greater Manchester Fire and Rescue Service and North West Fire Control have made alterations to the role of the National Inter-Agency Liaison Officer and Pre-Determined Attendance (PDA) protocols for terrorist-related and suspected terrorist-related incidents these organisations should test and further review these protocols to ensure …
Policing & Security
Accepted
Wessely Review — Rec 1
A purpose and a set of principles should be included in the Act itself.
Health & Social Care
Accepted
Modern Slavery Act Review — Rec 28
The website hosting the [modern slavery statements] repository should also clearly outline the minimum statutory reporting requirements.
Justice & Legal
Accepted
Modern Slavery Act Review — Rec 20
Guidance should make clear that reporting should include not only how businesses have carried out due diligence [to prevent modern slavery in their supply chains] but also the steps that they intend to take in the future.
Justice & Legal
Accepted
Modern Slavery Act Review — Rec 19
The statutory guidance [on transparency in supply chains] should be strengthened to include a template of the information organisations are expected to provide on each of the six areas [that a statement may cover].
Justice & Legal
Accepted
Stevenson/Farmer Review — Rec 11
We recommend that the Health and Safety Executive revise its guidance to raise employer awareness of their duty to assess and manage work-related mental ill-health.
Employment & Work
Accepted
Shawcross Review — Rec 12
Ensure high level decision-making within Prevent is always informed by proper consideration of the terrorism threat picture. This should ensure that any action taken is proportionate. The Homeland Security Group and Counter Terrorism Policing should be guided at strategic leadership level by a new 'Security Threat Check' – a series …
Policing & Security
Accepted
Shawcross Review — Rec 6
Revise the Prevent Duty to ensure the scheme meets its revised objectives. Amend the 2015 Counter Terrorism and Security Act to stipulate that relevant agencies must "have due regard to the need to prevent people from becoming terrorists or supporting terrorism". This alters the current duty to "have due regard …
Policing & Security
Accepted
Shawcross Review — Rec 1
Revise Prevent objective one of three in the duty guidance, and legislation where necessary, to clarify and emphasise the importance of tackling extremist ideology as a terrorism driver. Prevent's first objective should be to '"tackle the ideological causes of terrorism"'.
Policing & Security
Accepted
Fisher Review (Part 1) — Rec 20
The Consolidated Guidance should set out an expectation that investigators and prosecutors, on complex cases or cases with large volumes of digital material, should meet at least quarterly to discuss disclosure approach.
Justice & Legal
PHSO casework decisions(1)
LGO / SPSO decisions(2)
21-007-140 — West Lindsey District Council
Summary: There is evidence of fault by the Council. The Community Protection Notice served on a neighbour due to anti-social behaviour was not worded in a way that it was enforceable. In addition, when the Council got legal advice on the notice, it did not review or revise it to …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
21-008-290 — Uttlesford District Council
Summary: We found fault with the way the Council handled Mr C’s temporary event notice and the advice it gave about his party. The Council agreed actions to remedy the injustice to Mr C.
LGO (Local Government & …
Environment And Regulation
Upheld
Feb 2022
Domestic Homicide Reviews(92)— showing 50 strongest matches
Somerset — recommendation 3
All agencies who have been part of the review and any others deemed to be relevant by the Safer Somerset Partnership, to review their policies and procedures in relation to domestic abuse and consider the following points: Update domestic abuse policies/ procedures as required and implement. Adopt the same definition …
Safer Somerset Partnership
West Berkshire — recommendation 1
Operating procedures are up to date and reflect good practice i. By March 2015 undertake a review of SHA’s anti-Social Behavior, Domestic Abuse and Hate Behaviour Procedure and publish a revised/updated procedure. Measure of success: An appropriately approved, reviewed and updated Sovereign Anti-Social Behaviour, Domestic Abuse and Hate Behaviour Procedure …
Sovereign Housing Association
Haringey — recommendation 5
The Trust’s DV policy is updated to reflect these changes.
North Middlesex University Hospital NHS Trust
North Middlesex University Hospital …
Chiltern — recommendation FH NHS Recommendatio
Update the Domestic Abuse Policy to reflect current legislation and guidance.
Frimley Health NHS Foundation Trust | …
Frimley Health NHS Foundation …
Chiltern — recommendation Panel Recommendation
Thames Valley Police to review the TVP Safeguarding Policy which is currently dated 15/10/2009.
TVP
Elmbridge — recommendation 13
HM Government to develop the statutory guidance for DHRs to specifically include private medical care and oblige such organisations to participate in the DHR process.
HM Government
UK Government
Rochdale — recommendation iii
Rochdale MVOP panel to amend its practice and criteria to reflect the GMPs guidance in order to operate as the Mentally Vulnerable Offenders Panel (MVOP)
Rochdale MVOP panel
Barnsley — recommendation 7.2
Re-launch of Guidance for DHR's taking into consideration lessons learnt and updated guidance from the Home Office.
Community Safety Partnership
Kent — recommendation 21.
The Home Office should ensure that the definition of ‘personally connected’ in the Statutory Guidance for Section 76 of the Serious Crime Act 2015 is changed to ensure that all victims of domestic abuse are protected.
The Home Office
Home Office
Nottingham — recommendation 12.1
The Home Office should consider revising the Current Domestic Violence Disclosure Scheme (DVDS) Guidance to address situations where there are mutual allegations and identification of the primary perpetrator creates barriers to agencies correctly identifying the risks to the most vulnerable person in those cross allegations. We recommend that where there …
Home Office
Home Office
Buckinghamshire — recommendation Oxford Health Recomm
Team Managers from City AMHT will work with Service Manager to review, update, and relaunch the Operational Guide within the team, and review standard operating procedures (SOPs) following the remodelling of the team.
Oxford Health
Oxford Health NHS Foundation …
Brent — recommendation 18.1.1.
That the Home Office commission a review of the statutory guidance to include more detail about roles and responsibilities in the event of disputes between any combination of Panel Members, Chairs, report authors and the CSP. It is not uncommon for these to occur and the current guidance is ambiguous.
Home Office
Home Office
Southampton — recommendation 7
Force control room standard operating procedures are amended to provide clear risk based guidance on how to respond to calls from people with mental health issues.
Hampshire Constabulary
Hampshire and Isle of …
Southampton — recommendation 6
Force policies and procedures are amended to provide police officers with more guidance when dealing with suspects who have mental health issues.
Hampshire Constabulary
Hampshire and Isle of …
Aylesbury Vale — recommendation 6 (TVP)
Written Guidance on the closure of domestic incidents where victims refused to engage that is utilised by Contact Management should be incorporated in to the domestic abuse operational guidance.
Thames Valley Police
Thames Valley Police
Somerset — recommendation 21
Access policy and children’s DNA policy to be revised to clearly describe process for maternity users.
Musgrove Hospital
Somerset NHS Foundation Trust
Central Bedfordshire — recommendation 1.10.2
Case allocation and case closure sections within the operational policy will be updated by Integrated Services to reflect any revisions/improvements made within the system.
Central Bedfordshire Council Adult Social Care
Central Bedfordshire Council
South Cambridgeshire — recommendation 5
Inclusion’s domestic abuse policy is to be updated to include coercion and control. Their domestic abuse training is also to be updated to provide their staff with a clear understanding of what coercion and control is and the impact this has on individuals. The impact of drug and alcohol dependency …
Inclusion
Cornwall — recommendation 1
We recommend that there should be a clear and robust domestic abuse policy in place at each GP surgery in the county. These policies should be regularly reviewed by practice managers and subject to audit at regular intervals. Such a policy should be distinct and separate from policies relating to …
NHS Kernow | Kernow CIC
NHS Kernow
Tendring — recommendation 27
In light of the age of the documents entitled Court Issued Warrants Strategy (undated) and the accompanying schedule dated 2004, and more importantly, in light of the circumstances and learning from this case, this DHR considers that a review of the Policy in relation to warrants is carried out as …
Essex Police
Essex Police
Southampton — recommendation 4
That the Home Office consider allowing more flexibility in the guidance for DHRs to allow local Community Safety Partnerships to make a case for not completing such a review where the circumstance of a homicide do not fall within the spirit of the guidance, as for example in this case …
Home Office
Home Office
Northumberland — recommendation 3
The Home Office guidance regarding Adolescent to Parent Violence and Abuse (APVA) to be incorporated into the Single Point of Access (SPA) procedure and pathway to reflect the learning from this review and support a consistent, timely and appropriate response regarding adolescent to parent violence and abuse.
Northumberland County Council (Children’s Social Care)
Oldham — recommendation 8
The Home Office should update the Multi-Agency Guidance for the Conduct of DHRs to include signposting to the ‘Intimate Partner Homicide Timeline’, with a requirement that this is applied in the analysis of the circumstances in all future DHRs that involve intimate partner homicides. Where these type of DHRs conclude …
Home Office
Home Office
Oldham — recommendation 6
The Home Office should include signposting to any President’s Guidance issued on Judicial Co-operation with Domestic Homicide Reviews in the next update of the Home Office Multi-Agency Guidance for the Conduct of Domestic Homicide Reviews.
Home Office
Home Office
Oldham — recommendation 5
The Home Office, in consultation with the Department of Health and Social Care, and the Department of Education, should request the Ministry of Justice to recommend to the Office of the President of the Family Division that consideration be given to updating and expanding the 2017 President’s Guidance on Judicial …
Home Office
Home Office
Somerset — recommendation 18.8
Review the Call Handling Grading and Deployment Operational Procedure to try and identify those messages that present the greatest risk and require a prompt attendance.
Improvement and Assurance Officer for Domestic …
Portsmouth — recommendation 3
The DHR Author, the Portsmouth City Council Head of Service for Partnerships and Planning and the Portsmouth City Council Strategy and Partnership Manager to write to the Home Office to advise that homicides in the absence of coercion and control and power relationships do not fit easily within in the …
DHR Author | Portsmouth City Council …
Portsmouth City Council
Peterborough — recommendation 8
Cambridgeshire Police to review the current Homicide, sudden and unexplained death procedure (BCH09/009) to consider the requisite for the rank of Detective Inspector to attend all suicides.
Cambridgeshire Police
Cambridgeshire Constabulary
Liverpool — recommendation 9.10
The Partnership may find it beneficial to review guidance on the MARAC referral pathway to remind practitioners they are lawfully entitled (and may have a duty of care) to utilise powers under s42 Care Act to bring together practitioners with the adult at risk to formulate shared understanding of needs, …
Citysafe Partnership
Norfolk — recommendation R2
Recommendation 2: Update the template DA policy, bringing it up to date with changes in legislation, so as to encourage professionals to recognise indicators of, and routinely ask about domestic abuse.
GP/ICB
Doncaster — recommendation 4
Review and update the YAS policy ‘Domestic Abuse: Management Guidance’, to reflect the strengthened pathways for assessment and referral.
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Norfolk — recommendation 9
That all agencies review policies and procedures to ensure that they include the provisions of the Domestic Abuse Act 2021.
East London NHS Foundation Trust | …
East London NHS Foundation …
Norfolk — recommendation B
Review of Domestic Violence and Abuse Policies to ensure up to date information and correct local referral pathways reflected within the next three months.
Hackney ICB for General Practitioner (GP)
Gloucester — recommendation 2
To review the GHC Trust Domestic Abuse Policy as the current focus is for staff to know what to do in the event of a disclosure. More guidance is required within this policy about the indicators of potential domestic abuse to enable more effective signposting to specialist services.
Gloucester Health and Care NHS Foundation …
Coventry — recommendation 9
Coventry Safeguarding Adult Board should ensure that the multi-agency dual diagnosis policy (which is out of date) is refreshed between CGL, Coventry and Warwickshire Partnership NHS Trust and other mental health providers and overseen by commissioners of those services.
Coventry Safeguarding Adult Board
Bath and North East Somerset — recommendation R14
Relevant DHI policies and procedures to be reviewed to consider appropriateness of current thresholds for action
DHI
Bath and North East Somerset — recommendation R7
During the Review it was identified that B&NES does not appear to have a clear multi-agency policy / procedure on Domestic Abuse and Violence or a multi-agency training programme.
B&NES Responsible Authorities Group(Community Safety Partnership)
Bath and North East Somerset — recommendation R4
The Operating Protocol in relation to Safeguarding decisions between AWP and Bath and North East Somerset Council needs to be reviewed particularly in relation to alerts having to be made by Team Managers or Senior Practitioners
AWP and Bath and North East …
Sefton — recommendation 11
To include when capacity and consent is not relevant on the Flow Chart – e.g. when a crime has been committed Policy due for review August 2016- this incident to inform the review
Southport and Ormskirk Hospitals NHS Trust
Kent — recommendation 3
Kent Police must review its domestic abuse policy regularly to ensure that it describes the service that victims can expect. Having done so it must ensure that the policy and associated guidance are complied with.
Kent Police
Kent Police
Kent — recommendation 1
Kent Police must examine its initial response to calls made by the victim between 2 November and 7 November and amend policies and guidance in order to ensure that the lessons learned from this review are incorporated.
Kent Police
Kent Police
Kent — recommendation 19.
KMDASG should agree a process that ensures minutes are taken at all MARAC meetings and include this in the Kent and Medway MARAC Operating Protocol and Guidelines.
KMDASG
Kent — recommendation 11.
CCGs in Kent and Medway should provide guidance to GPs about providing records when requested as part of a DHR, taking account of Section 10 of the Multi-Agency Statutory Guidance for the Conduct of Domestic Homicide Reviews.
ICBs in Kent and Medway
Ceredigion — recommendation 15.7j
The UHB should highlight the fact that the safeguarding matrices in the All-Wales Clinical Governance Self-Assessment Tool (CGPSAT) are outdated and require review.
Hywel Dda University Health Board
Hywel Dda University Health …
Bedford — recommendation 1
The Ministry of Justice to develop guidance for prisons in relation to their role in the DHR process, including the pro-active steps they should take to enable engagement with perpetrators.
Ministry of Justice
Ministry of Justice
Nottingham — recommendation 10.2a
Where procedures outline expected discharge actions there is enough flexibility within services to respond differently when necessary.
Nottingham Recovery Network
Lambeth — recommendation 3
The Home Office to work with other government departments to develop a cross-government definition of AFV/CPV. This should include developing policy and practice guidance for AFV and refreshing the current CPV guidance.
Home Office
Home Office
Solihull — recommendation 5
That West Midlands Ambulance Service should review the SADPERSON risk assessment tool currently used by responders to predict future suicide or repetition of self-harm, in the light of current NICE guidance giving specific consideration to the fact that it should not be relied upon for this purpose. The service should …
West Midlands Ambulance Service
West Midlands Ambulance Service …
Bournemouth — recommendation 9.7
Ministry of Justice review the storage policy of Women Safety Worker records. Probation Women’s Safety Workers records were absent in this case having been destroyed after five in storage in accordance with current guidelines. I know this to be an issue for other DHRs and the Review requests that the …
Ministry of Justice
Ministry of Justice
Chelmsford — recommendation 1
Completion of the review of the NELFT policies and procedures on domestic violence.
North East London Foundation Trust
North East London NHS …