Outdated Operational Guidance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 16 independent accountability sources, so the source mix matters as much as the headline total.
102 inquiry recs
220 PFD reports
59 committee recs
16 HSSIB recs
52 CQC actions
9 ICIBI recs
10 PPO recs
76 IOPC recs
1 NAO rec
2 IMB recs
1 patient safety alert
16 Scottish FAIs
2 detention investigation 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(102)— showing 50 strongest matches
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 08/2012, which sets out the mandatory actions for young offender institutions and secure training centres for 'maintaining a safe and secure environment', has expired. The Chair and Panel recommend that the …
Gov response: On 23 July 2019, the Ministry of Justice stated that work had begun to revise or replace Prison Service Instructions (PSIs) with 'policy frameworks'. In advance of updating PSI 08/2012, the Youth Custody Service published …
Accepted
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: Accepted.
Accepted
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.
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: No formal response published by this government.
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: No formal response published by this government.
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: No formal response published by this government.
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: Department for Business and Trade accepts this recommendation. DBT, Post Office, and Fujitsu have jointly embarked on a postmaster-led restorative justice programme facilitated by the Restorative Justice Council. Sessions began on 23 September 2025. A …
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: Department for Business and Trade accepts this recommendation. Some close family members of postmasters suffered serious adverse consequences because of the Horizon scandal. DBT is committed to establishing a redress scheme for close family members …
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: Department for Business and Trade acknowledges this recommendation and sees clear advantages in establishing a standing public body for financial redress. However, the government recognises that establishing such an independent redress body requires careful consideration …
Response Unclear
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: Department for Business and Trade accepts this recommendation. DBT confirms that HCRS applies identical principles to the previous OCS scheme, ensuring no disadvantage to overturned conviction claimants. Case management and independent panel processes are in …
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: Post Office agrees that closure of the scheme represents an important milestone in providing overall closure for postmasters and we welcome the opportunity to do so. [...] After careful thought, and in consultation with DBT, …
Accepted in Part
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 agreed that instead of a nine-month period for postmasters to submit a full appeal there should be a three-month deadline to notify the Department of an …
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: Department for Business and Trade accepts this recommendation. The "best offer" principle applies equally across GLO, HSSA, and HCRS schemes at all panel stages. This has been in effect since 12 August. DBT will retrospectively …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
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: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-53 — CPS protocol for section 35 prosecution takeover
Recommendation: It is recommended 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 …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-45 — Ensure effective explosive detection dog deployment
Recommendation: His Majesty's Inspectorate of Constabulary and Fire and Rescue Services, Counter Terrorism Policing Headquarters and the College of Policing should take steps to ensure that all police services have in place effective systems for the prompt deployment of explosives detection …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-43 — Guidance on covering deceased at mass casualty scenes
Recommendation: Guidance should be provided to event healthcare providers, to emergency service responders other than paramedics and to the public generally about the circumstances in which those who are believed to be dead should be covered. The guidance should make clear …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-41 — Include NWAS capabilities in GMP Major Incident Plan
Recommendation: Greater Manchester Police's Major Incident Plan should be reviewed to ensure that it includes clear guidance on the capabilities of North West Ambulance Service, including its Hazardous Area Response Team, Ambulance Intervention Team and Special Operations Response Team, as well …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-40 — Include GMFRS capabilities in GMP Major Incident Plan
Recommendation: Greater Manchester Police's Major Incident Plan should be reviewed to ensure that it includes clear guidance on the capabilities of Greater Manchester Fire and Rescue Service, including its Specialist Response Team, as well as on the importance of joint working.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-39 — Single consolidated GMP Operation Plato plan
Recommendation: Greater Manchester Police should review its Operation Plato plans to ensure that there is only a single plan to which all can work and that this plan gives clear and consistent guidance on how to respond to an Operation Plato …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-37 — Ensure GMP role cards are accessible
Recommendation: Greater Manchester Police should ensure that its role cards are always immediately accessible to the officers who are to perform those roles
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-36 — Regular expert review of GMP Major Incident plans
Recommendation: Greater Manchester Police should ensure that its plans for responding to a Major Incident, including a terrorist incident, are reviewed regularly by those with the appropriate skills and experience to make meaningful improvements to each plan. This must include a …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-35 — Review GMFRS Incident Commander policy
Recommendation: Greater Manchester Fire and Rescue Service should review the policy by which the Incident Commander takes up the role, in light of the shortcomings I have identified in the policy in operation on 22nd May 2017.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-34 — Review GMFRS information sharing during incidents
Recommendation: Greater Manchester Fire and Rescue Service should review its guidance and policies on how it receives and passes on information during a Major Incident. It is important that, for any update given, it is established when the last time the …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-31 — Joint GMFRS/NWFC incident log review procedures
Recommendation: Greater Manchester Fire and Rescue Service and North West Fire Control should conduct a joint review of the circumstances in which it is appropriate for Greater Manchester Fire and Rescue Service personnel to check the North West Fire Control incident …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-27 — Review terrorist attack notification procedures
Recommendation: Counter Terrorism Policing Headquarters should review the procedures by which it is notified of a terrorist attack to ensure that all police services know that this is an early priority.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-24 — Review combined vs separate Gold/Silver Control Rooms
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should review the advantages and disadvantages of a combined Silver and Gold Control Room as opposed to separate rooms, and issue guidance for all police services on best practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-23 — Guidance on Silver command deployment to scene
Recommendation: Counter Terrorism Policing Headquarters and the College of Policing should issue guidance on the circumstances in which a police officer or officers with responsibility for the tactical/silver command of the unarmed officers at the scene or scenes of a Major …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
MAI-15 — Ensure prompt BTP Bronze Commander appointment
Recommendation: British Transport Police should review its procedures to ensure the prompt appointment of a Bronze Commander during a Major Incident.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
BAHA-34 — Consistent Sight Deprivation Terminology
Recommendation: Theatre level detention instructions and guidance should be reviewed to ensure that references to the means of permissible sight deprivation are consistent. The clearest wording is likely to be 'sight deprivation by blacked-out goggles'.
Gov response: Accepted. Terminology has been standardised to 'sight deprivation by blacked-out goggles'.
Accepted
BAHA-32 — SOI J3-9 Sight Deprivation
Recommendation: SOI J3-9 should reflect the greater emphasis that is given in the latest draft of JDP 1-10 to avoiding in the first place, where practicable, circumstances in which sight deprivation may be necessary. More generally, it should reflect the five …
Gov response: Accepted. SOI J3-9 has been updated to emphasise avoiding sight deprivation where practicable.
Accepted
Prevention of Future Deaths reports(220)— showing 50 strongest matches
Jared William McDowall
Concerns: Inadequate guidelines for identifying at-risk babies, including a lack of specific weight-for-gestation criteria and poor data presentation. Joint training for doctors and midwives on hypoglycaemia is also needed.
Response (University Hospital Bristol): University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Responded
Isabella Hope Hill
Concerns: Hospital guidelines for umbilical venous catheter insertion, specifically requiring an X-ray to confirm position, were not followed, indicating sub-optimal practice and a need for improved guidelines and staff training.
Response (Liverpool Womens NHS): The Trust has enhanced local education for staff on the Neonatal Unit regarding revised guidelines, reviewed and clarified the Service Level Agreement for Radiology to ensure X-rays are performed within …
Responded
Wilhelmina Isobel Newton
Concerns: The care home lacked clear written protocols and guidance for staff on responding to head injuries in elderly residents, particularly those on anti-clotting medication.
Response (Cumbria County Council): Cumbria County Council has reviewed the issues regarding procedures to be followed when a resident sustains or is suspected of sustaining a head injury and updated their policy, embedding it …
Responded
Yousef Shokri-Gharab
Concerns: An outdated and unreviewed policy for informal patient leave failed to reflect current practice, risking patient safety due to lack of multidisciplinary consensus and proper documentation.
Response (Mersey Care NHS Foundation Trust): • The Corporate Governance Team have been tasked with ensuring that all policies are received and updated to ensure that reflect national best practice. • Of the 120 Corporate Policies …
Responded
Scarlett Sinclair
Concerns: The policy for assessing a baby's wellness and stability prior to transfer between neonatal units needs urgent review, as babies are being transferred in an unstable condition.
Overdue
Keith Martin
Concerns: Systemic delays in A&E assessment, diagnostics, senior review, and treatment for chest pain, combined with unclear protocols and poor documentation, resulted in critical care failures.
Overdue
Adrian Cowan
Concerns: The trust's emergency policy lacked clear guidance and a requirement to call a duty doctor, and nursing staff were unable to calmly apply basic life support training during a patient collapse.
Response: Barnet, Enfield and Haringey Mental Health Trust has reviewed and updated the Trust’s resuscitation policy to include additional action to be taken in response to the “deteriorating patient”. They have …
Overdue
Vincent Gibson
Concerns: Police incident management suffered from unclear leadership, inadequate communication protocols, ineffective resource allocation, and unreliable electronic aids, compromising response safety and efficiency.
Overdue
Thomas Smith
Concerns: Critical issues include incomplete handovers, slow response times for children, lack of ambulance transfer, outdated national guidance on pre-hospital antibiotics for meningitis, and fragmented hospital care with unaddressed nursing concerns.
Overdue
Nathan Healer
Concerns: A newborn's severe condition was not appreciated, leading to a missed opportunity for timely blood glucose testing despite existing hospital and NICE guidance. There is a delay in finalising and implementing updated national guidance for neonatal hypoglycaemia management.
Response (Department of Health): The Department of Health notes the concerns raised regarding the NICE guideline CG63 and its review. They state that draft guidance is due to go out for consultation in September …
Responded
Faye Rippon
Concerns: Current protocols for late terminations of pregnancy (21/40 gestation) are inadequate as they lead to live births, causing distress and conflicting with the intent of Abortion Act amendments. Foeticide should be considered before induction at this stage.
Overdue
Clive Turner
Concerns: Hospital staff lacked knowledge of pre-hospital pain relief, there were no clear policies for overnight patient discharge, and senior clinical oversight was unavailable late at night.
Response (Welsh Ambulance Service NHS Trust): The Welsh Ambulance Service reviewed the delayed response, implemented a new clinical support desk for early triage of calls, staffed by paramedics and nurses, using the Manchester Triage System. This …
Responded
Caroline Carter Crowther
Concerns: Contradictory policies and training regarding compelling psychiatric patients to hospital, with paramedics uncertain about their authority to physically coerce grievously ill patients.
Overdue
Elouise Winship
Concerns: There is no documented standard practice for regular fetal heart auscultation after opiate administration or for further maternal examinations following a change in condition during labour.
Overdue
Elsie Plumb
Concerns: The Royal College of Obstetricians and Gynaecologists' guideline on preventing neonatal Group B Strep disease is ambiguously worded regarding the timing and necessity of antibiotic prophylaxis during labour induction.
Overdue
Phyllis Kerry
Concerns: There is a lack of clear, communicated guidelines for managing patients with intra-cerebral bleeds while on Warfarin, leading to uncertainty about clinical responsibility and treatment protocols.
Response (Nottingham University Hospitals NHS Trust): A new guideline has been prepared to improve the management of anticoagulation in patients with intracerebral hemorrhage, clarifying specialty responsibilities. The specialties involved are currently consulting with colleagues to finalize …
Response (Nottingham University Hospitals NHS Trust2f): A new guideline for treating warfarin patients with intracranial hemorrhage has been agreed and will be communicated to medical staff and included in specialty inductions. The guideline group will also …
Responded
Francoise Snape
Concerns: No VTE assessment was performed due to staff misconceptions and perceived busyness. Staff also lacked knowledge of NICE guidelines regarding DVT prevention and mechanical anti-DVT devices, representing a lost opportunity for care.
Overdue
Mohammed Yousaf
Concerns: There are no national guidelines on how to interpret and/or classify antenatal CTG tracings, and there were concerns about the dissemination, application, and applicability of the Trust’s Interpreting Policy, specifically regarding obtaining informed consent.
Overdue
Lexie Harrison
Concerns: A critical lack of national and local standardised policies for paediatric oesophageal varix banding procedures leads to inconsistent consultant practices. This impacts patient assessment, post-procedure care, and bleeding management.
Response (The Leeds Teaching Hospitals NHS Trust): The Trust shared the coroner's report with relevant staff and clarified their existing guidelines for managing bleeding oesophageal varices, including resuscitation, antibiotic use, Sengstaken tube placement, and banding procedures. They …
Response (Cardiff and Vale University Health Board): The UHB acknowledges the coroner's concerns regarding the lack of standardized practices for paediatric endoscopy procedures, but states that they are unable to take the concerns forward themselves and suggest …
Overdue
Paige Bell
Concerns: Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.
Response (Northumberland Tyne Wear NHS Trust): The Trust believes there was confusion about contradictions in the observation policy. While acknowledging improvements are needed in recording information, they state that information was shared and available to decision-makers.
Response (Department of Health): The Department of Health acknowledges the concerns regarding electronic patient records, national policy on patient engagement and observation, and NICE guidelines for Borderline Personality Disorder. They describe existing systems and …
Responded
Michael Pollard
Concerns: An outdated hospital switchboard rota led to critical delays in contacting the correct on-call consultant for an emergency, highlighting a need for a centrally managed, up-to-date system.
Response (University Hospitals of Leicester NHS Trust): University Hospitals of Leicester NHS Trust's Interim Medical Director has written to all doctors reminding them of their obligations to ensure that switchboard are informed of any amendments to the …
Responded
David Bladen
Concerns: There is an absence of clear guidance for optimal thromboprophylaxis management in patients with restricted mobility due to braces, but not in casts.
Response (National Institute for Health and Care Excellence): NICE acknowledges the coroner's concerns about a lack of national guidance on VTE prophylaxis for patients in lower limb braces. NICE's clinical guideline (CG92) on VTE recommends mechanical VTE prophylaxis …
Responded
Thomas Beaty
Concerns: Guidance on instrumental delivery was ambiguous and potentially open to misinterpretation, lacked operational definitions for terms like 'imminent', and the term 'gentle' traction was misleading; furthermore, it's difficult for Trusts to change guidance until the RCOG issues changes/improvements.
Response (Department of Health): The Department of Health acknowledges the concerns raised about RCOG guidance and has forwarded the coroner's report to the RCOG.
Response (Pennine Acute Hospitals): The Pennine Acute Hospitals Trust reviewed and revised the Guideline for Assisted Vaginal Delivery to provide staff with greater clarity and guidance regarding consultant presence for trial in theatre. The …
Overdue
Michael Quinn
Concerns: Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.
Overdue
Dean Joseph
Concerns: Inconsistent understanding of armed containment, lack of trained negotiator guidance for first responders, and sub-optimal post-incident procedures undermined the investigation and public confidence.
Response: The MPS has directed the post incident manager (PIM) to consult with the DPS and the IPCC to decide on what reference materials are proposed to be used by officers …
Responded
Glenda Day
Concerns: A doctor granted home leave without reviewing the patient or updating risk assessments, exposing a lack of clear written policies and consistent, trust-wide adherence to safe home leave procedures.
Overdue
Stefen Boswell
Concerns: Inconsistent police pursuit policies between local and national guidelines on wrong-way driving, coupled with inadequate communication systems for critical pursuit details, created unnecessary risks.
Response (West Mercia Police): West Mercia Police and Warwickshire Police have harmonised policies and procedures with the Authorised Professional Practice (APP) for police pursuits. All police vehicles entering service are now fitted with an …
Responded
Carl Dickerson
Concerns: Regulatory loopholes allow non-commercial flights from unlicensed aerodromes to operate in conditions prohibited for commercial ventures, despite previous accidents and unimplemented recommendations for a special aviation category.
Response (CAA): • The CAA has instigated a thorough review of the rules applicable to flights performed under Instrument Flight Rules (IFR) outside controlled airspace through our Safety Review Committee. • This …
Responded
Douglas Kay
Concerns: There was significant confusion and lack of clear policy regarding transferring patients with gastrointestinal bleeding, compounded by senior staff's unawareness of new service operations, particularly out of hours.
Response (DBH Trust): The Trust developed an Upper GI Bleed Transfer Policy for Bassetlaw Hospital after consultation between anaesthetic and medical teams. Staff will be made aware of the policy, and it will …
Responded
Joseph Sarkozi
Concerns: Fire officers prematurely concluded dust on ceiling lights caused a fire without positive evidence, highlighting a need for improved investigative practices and national learning dissemination.
Response (Avon Fire PFD): Avon Fire & Rescue will include the incident scenario in training packages for operational crews, notify personnel via the "Fire Alert" system, amend the Domestic and Residential Fires risk card, …
Overdue
Wilfred Pearson
Concerns: Concerns include outdated treatment protocols, poor medical notes, inadequate care escalation, and severe junior medical staff shortages. The patient was also unlawfully detained.
Response (W Pearson): Tameside Hospital NHS Foundation Trust revised the Status Epilepticus Policy twice since Mr. Pearson's admission, including references to recent guidance in the Lancet Medical Journal. They have also provided MCA/DOLS …
Responded
Derrick Twiate
Concerns: Dispensing pharmacists continue a practice, contrary to professional advice, of snipping tablets from unit dose packs into multi-dose compliance aids, risking drug integrity and patient safety.
Overdue
Curt Falk
Concerns: A patient died from a viral infection (SCC) preventable by vaccination, but current policy excludes males from this vaccination, indicating a risk of future deaths in men from this infection.
Response (JCVI): Public Health England will submit work on the cost-effectiveness of extending the HPV vaccination programme to adolescent boys to JCVI by early 2017. In November 2015 JCVI advised that a …
Overdue
Christ Morrison
Concerns: Concerns centred on unclear training standards and lack of medical presence during paediatric tracheostomy tube changes, with a policy for emergency transfer rather than onsite re-intubation in case of failure.
Response (Epsom and St Helier NHS Trust): Epsom and St Helier University Hospitals NHS Trust reviewed and updated the Trust's 2015 Tracheostomy Policy to give clearer sign posting to national guidelines. The updated policy has been submitted …
Overdue
Edward Paddon-Bramley
Concerns: Significant discrepancies exist between national guidelines (NICE) and local Trust practices/consultant views regarding the treatment of prolonged rupture of membranes and Group B Strep screening in pregnancy.
Response (NSC): The UK NSC commissioned an update review into antenatal screening for GBS in December 2015 and expects to hold a public consultation in the autumn for three months, after which …
Response (Department of Health): The Department of Health notes concerns about differing guidelines for prolonged ruptured membranes (PROM) and GBS screening. They highlight that NICE guidelines represent best practice and that the RCOG provides …
Overdue
Marjorie Booth
Concerns: Concerns were raised about an apparent hospital policy not to routinely perform CT scans for suspected fractures, even when the risk of missing a fracture outweighs radiation exposure risk for elderly patients.
Overdue
Alan Dimbleby
Concerns: Self-propelled sprayers lack operator seat restraints, risking operators being thrown from the vehicle if it overturns. HSE guidance may inappropriately suggest these restraints are not needed for this vehicle type.
Response (Bateman Engineering Ltd): Bateman Engineering has changed the design of their cabs to include seat restraints, and now fits them on all vehicles before they leave the workshop.
Response (Alan DIMBLEBY): HSE will raise the issue of seat restraints on self-propelled sprayers at the next appropriate meeting for consideration in future revisions of applicable standards and will consider revising guidance to …
Overdue
Mark Seward
Concerns: A lack of clarity on pressure testing definitions and widespread non-compliance with work equipment regulations (PUWER) and HSE guidance across the industry posed significant safety risks.
Response (SEWARD): The company has reminded staff about the health and safety policy, reviewed the site safety induction, and introduced a new traffic management plan. They have also invested in new health …
Overdue
Helen Patton
Concerns: Mini Tracheostomy Procedures pose an ongoing mortality risk due to being frequently performed outside theatre and without ultrasound guidance. A critical lack of national guidelines exacerbates these risks.
Response (Department of Health): The Department of Health acknowledges concerns regarding mini tracheostomy procedures, and includes a joint response from the Faculty of Intensive Care Medicine (FICM) and the Royal College of Anaesthetists (RCOA). …
Response (The Royal College of Anaesthetists): The Faculty of Intensive Care Medicine and Royal College of Anaesthetists reviewed information about a death following a minitracheostomy, but state the provided data is inadequate to answer questions definitively …
Responded
Henry Hicks
Concerns: Police officers failed to identify a situation as a pursuit and seek authorisation, contrary to the jury's determination, implying non-compliance with the Metropolitan Police Service's standard operating procedure.
Response (Metropolitan Police Service): The Metropolitan Police states that the existing pursuit policy remains unchanged but will be fully explored in the context of a formal disciplinary process for the officers involved, and notes …
Responded
Khazna Khalaf
Concerns: Local protocols and hospital guidelines were ineffective in alerting clinicians to ecstasy toxicity risks and symptoms, lacking a clear clinical protocol for initial intervention decisions and monitoring.
Overdue
Robert Dearing
Concerns: Unregulated, non-standard anti-glare visors significantly obscured driver vision due to extremely low light transmission. A lack of legislation and British Standard certification for these devices poses a safety risk.
Overdue
Samantha Hopkins
Concerns: Critical trial exclusions, such as for pregnant women, were overlooked due to insufficient prominence on drug packet warnings and lack of guidance for highlighting these exclusions.
Response (South Central Ambulance Services NHS Trust): New labels detailing exclusion categories will be placed on further issues of the trial drug packs. SCAS has committed that by January 2017 that all trial drugs in circulation will …
Response (Warwick Medical School): The University has instructed participating Ambulance Services to issue a reminder to all participating staff, to reiterate the inclusion and exclusion criteria for the trial. Compliance with this instruction shall …
Responded
Denis Cronin
Concerns: Significant failings in dive training, planning, and risk assessment led to an unqualified diver teaching an inexperienced individual. Important safety information was ignored, and equipment design posed a release risk.
Response (Denis Cronin Response2): BSAC is rewriting its core Diver Training Programme to include a skills sheet for instructors to sign off individual skills. BSAC will also produce a guidance document on weightbelt removal …
Response (Denis Cronin): Dulwich BSAC 102 will develop a means of recording partial training completion. They will also seek clarification from BSAC regarding sequencing of lessons and guidance on DSMB use.
Responded
Colin Wellings
Concerns: Current legislation exempts older, powerful vehicles from essential safety requirements like helmets or seatbelts, posing significant risks to riders and other road users.
Response (Department for Transport): The Department for Transport acknowledges the concerns, explains current regulations regarding tricycle helmets and licensing, and notes that changes to collision reporting codes and helmet regulations are not planned but …
Responded
Nihad Ousta
Concerns: There is a critical absence of written protocols or guidance for head injury management, specifically regarding the frequency and range of necessary general and neurological observations.
Overdue
Barbara Turner
Concerns: The Trust's resuscitation policy has overly broad call-out criteria, risking critically ill patients being denied care. Patient transfer protocols were dangerous due to insufficient monitoring, escort, and emergency equipment.
Overdue
Frederick Squires
Concerns: A lack of clear clinical guidance on when to reintroduce Warfarin after a head injury risks either premature commencement leading to bleeding, or delayed commencement causing stroke.
Response (National Institute for Health and Care Excellence): NICE acknowledges the lack of guidance on when to restart Warfarin after a head injury. They will consider extending the scope of their existing head injury guideline in 2017 to …
Responded
James Fox
Concerns: Concerns were raised about the accuracy of close-range police firearms, lack of less-lethal options, inadequate contingency planning for volatile situations, and inconsistent national training for officers.
Response (Metropolitan Police Service): The Metropolitan Police defends its officers' actions and states that there is no indication of misconduct. The IPCC investigation reported no matters of organisational learning other than a positive comment …
Responded
Joyce Crompton
Concerns: The care home lacked written policies, systematic checklists, and refresher training for Speech and Language Therapy (SALT) referrals, leading to missed assessments for residents after choking incidents.
Response (Belong): Belong has reminded managers and nurses of policy adherence, requested reassessment of residents' choking risk, updated staff training, and will review policies in a meeting with registered managers. Staff at …
Responded
Select committee recommendations(59)— showing 50 strongest matches
#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 Pending
#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 Pending
#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 Pending
#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 Pending
#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 Pending
#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 …
Gov response: We agree that reproductive health is an important area for the development of clinical guidelines. NICE has identified women’s and reproductive health as a priority area for guideline development, and already has an extensive portfolio …
Position Not Stated
#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.
Gov response: We agree that all students, including both girls and boys, should receive comprehensive education on menstrual health, and that all girls and women should be informed on what a ‘normal’ period is. Relationships, sex and …
Response Not Attributed
#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 …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: September 2026 6.2 The government agrees that the current guidance that has been provided to local highway authorities through the ‘Code of Practice for …
Accepted
#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 …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: September 2026 6.2 The government agrees that the current guidance that has been provided to local highway authorities through the ‘Code of Practice for …
Accepted
#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 …
Gov response: The government agrees with the Committee’s recommendation. highway authorities through the ‘Code of Practice for Well Managed Highway Infrastructure’ document should be refreshed. The department has commissioned TRL to work with the sector to develop …
Accepted
#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 …
Gov response: Partially Agree. We agree that research must address the interconnected factors impacting nutrition and food systems in order to effectively fight hunger. That is why, the FCDO has adopted a food systems approach to tackling …
Partially Accepted
#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 …
Gov response: Defra recognises the role that the Marine Policy Statement (MPS) plays in setting a high-level context for marine planning and the development of marine plans. The key documents which guide spatial planning decisions are marine …
Position Not Stated
#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)
Gov response: The Government therefore disagrees with this recommendation to update the UKMPS and that it is possible to do so in 6 months. Defra recognises the role that the Marine Policy Statement (MPS) plays in setting …
Response Not Attributed
#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 …
Gov response: 6.1. The Government agrees that public procurement is a powerful lever for driving economic growth in the UK. The Industrial Strategy set out how the Government will implement current reforms and also go further to …
Accepted
#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 …
Gov response: 4.1. The Trade Strategy and the Industrial Strategy were developed together, and they will work together hand-in-glove to give UK businesses the support they need to invest and grow. 4.2. The Trade Strategy sets out …
Position Not Stated
#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 …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#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 …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#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 …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#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 …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: December 2025 2.2 The development of the Digital Commercial Strategy will include an agreed approach to supplier and market engagement, with a particular focus …
Accepted
#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 …
Gov response: 3.5 The government agrees with the committee’s recommendation. Target implementation date: December 2025 3.6 The government is taking forward the actions outlined below on which we will update the Committee on progress in December 2025: …
Accepted
#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 …
Gov response: The government agrees with the Committee’s recommendation. to supplier and market engagement, with a particular focus on Small and Medium Enterprise and Voluntary, Community and Social Enterprise suppliers, working in conjunction with industry representative bodies …
Accepted
#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 …
Gov response: The Government partially accepts this recommendation.
Partially Accepted
#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 …
Gov response: The Government partially accepts these recommendations. 75. NERC has a well-established framework for reviewing, prioritising and implementing any necessary changes related to infrastructure support to enable excellent marine and polar science delivery. The Cruise Programme …
Partially Accepted
#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 …
Gov response: The Government partially accepts this recommendation.
Partially Accepted
#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 …
Gov response: The proposed amendments to the NPSs mean that the CSNP will only be endorsed when certain steps have been completed, which include completing public consultation and relevant environmental assessments and publication on NESO’s website. Similarly, …
Partially Accepted
#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 …
Gov response: reviewing the reference to the CSNP displaying “indicative routes” in paragraph 3.3.80;
Position Not Stated
#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 …
Gov response: The CSNP will provide strategic level recommendations for transmission infrastructure based on system need and project demand from the SSEP chosen pathway, ensuring that project level details (such as routing) can be explored and consulted …
Partially Accepted
#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 …
Gov response: The overarching energy NPS EN-1 contains guidance on how applicants should manage securing a grid connection for their proposed development and the interaction with their application for development consent. EN-1 Section 4.11 states that the …
Accepted
#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)
Gov response: In current guidance, the Department does not prescribe a specific model of FGDM; however, local authorities are encouraged to consider the evidence for the Family Group Conference model. It is a local authority’s decision on …
Position Not Stated
#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 …
Gov response: Economic security cooperation on areas outlined in the EPD, including investment screening and export controls, will ensure that the UK and US focus on outcomes reflecting our shared national security interests. We will continue to …
Position Not Stated
#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 …
Gov response: The Place of Destination (PoD) scheme, introduced in January 2021, was explicitly designed as a temporary measure to facilitate plant health checks on high-risk goods inland during the post-EU Exit transition period. This approach was …
Partially Accepted
#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 …
Gov response: As set out in previous responses, the Government is also reviewing, and updating as necessary, the existing Appraisal of Sustainability and Habitats Regulations Assessment, in line with any amendments made to the ANPS. These assessments …
Under Consideration
#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)
Gov response: 23. On 28 January 2026 we responded to our consultation on an updated and modernised Decent Homes Standard. The new, modernised DHS is designed to meet modern expectations of housing quality. By setting out in …
Response Not Attributed
#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 …
Gov response: The Government partially agrees with this recommendation. The Government disagrees that the Bill needs to be amended to ensure that the relevant policies, standards and commitments could be considered by a court when making a …
Response Not Attributed
#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 …
Gov response: The Government notes this recommendation. The Government welcomes the Committee’s support for an aligned set of duties across key industry bodies within the Railways Bill. However, as the ORR explained to the Committee, the Railways …
Position Not Stated
#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 …
Gov response: The Government notes this recommendation. The Government welcomes the Committee’s support for an aligned set of duties across key industry bodies within the Railways Bill. However, as the ORR explained to the Committee, the Railways …
Response Not Attributed
#7 — Update Committee on progress resolving Carer’s Allowance overpayments due to inaccurate guidance
Recommendation: Inaccurate operational guidance has led the Department to incorrectly assess around 26,000 carers as having been overpaid Carer’s Allowance. The main cause of Carer’s Allowance overpayments is claimants having earnings which exceed the permitted limit. The Independent Review of Carer’s …
Gov response: The government agrees with the Committee’s recommendation. review and has appointed a Senior Responsible Owner to make sure it delivers on these. The department has already increased the weekly Carer’s Allowance (CA) earnings limit by …
Accepted
#21 —
Recommendation: Most landlords recognise their responsibility to provide tenants with a safe, decent and comfortable home. The government nationally and locally has a role to reduce unintentional non-compliance by educating landlords about their legal responsibilities and supporting them to adopt more …
Response Pending
#32 — United Nations peacekeeping missions require reforms, including technology and regular reviews.
Recommendation: However, we recognise that United Nations peacekeeping missions require reforms to ensure they are fit for purpose. This should include consideration of technological solutions—like the use of drones for monitoring conflict zones—to both support United Nations peacekeeping missions and reduce …
Gov response: Agree. 43. HMG agrees that UN peacekeeping remains an indispensable tool for peace and agrees with the need for UN peacekeeping reform as part of the UN80 process. HMG’s overarching reform objective is for peacekeeping …
Partially Accepted
#5 — Government updating ANPS; Heathrow airport expansion decision linked to new ANPS publication.
Recommendation: The Government has confirmed that it is updating the Airports National Policy Statement (ANPS). We welcome the letter from the then Aviation Minister, Mike Kane MP, to the Committee following his appearance which confirmed that the Heathrow decision would not …
Gov response: As part of the ANPS review, DfT is considering how the Government’s four tests for Heathrow expansion, including for noise, should be set. The review is considering changes in legislation, policy and data since the …
Under Consideration
#9 — Make clear to DCO applicants the burden of evidence required against each criterion.
Recommendation: Guidance must make clear to applicants the burden of evidence required against each criterion. Should a pipeline of DCO applications materialise, this guidance should be regularly updated as lessons are learned, rather than waiting for the next NPS review. (Recommendation, …
Gov response: We agree that the guidance must make clear to applicants the expectations for each criterion in EN-7. We judge that EN-7 provides sufficient information on the expectation of developers when considering each criterion. The information …
Position Not Stated
#17 —
Recommendation: The government must ensure that the private rented sector database includes, as a minimum, information on the condition and accessibility of privately rented properties, including details of previous enforcement actions, and the current rent and rent histories. Following the initial …
Response Pending
#32 — Establish a Zero Hunger strategic delivery framework by 2025 with clear guidance for FCDO programming.
Recommendation: We recommend that by the end of 2025 a Zero Hunger strategic delivery framework is created that acknowledges the complex interrelationships between climate, gender, disability, conflict, food security and nutrition. The framework should have clear and practical guidance for civil …
Gov response: Partially Agree. We agree, in principle, that any HMG work towards achieving a world without hunger and malnutrition should be guided by a common approach to ensure a coordinated approach across government departments and effective …
Not Addressed
#24 — Lead a review of transport accessibility legislation, collaborating with disabled people, to update and clarify standards.
Recommendation: The Department for Transport should lead a review of transport accessibility legislation in collaboration with the Office for Equality and Opportunity, and with meaningful involvement and leadership by disabled people, to assess how it could be streamlined, clarified and updated, …
Gov response: 28. The Department accepts the need to look again at the legislative framework for accessibility in transport. The inquiry has highlighted the complex nature of the legislative framework that has grown over the years and …
Not Addressed
#23 — Transport accessibility legislative and regulatory framework is overly complicated and fragmented.
Recommendation: The landscape of legislative and regulatory requirements for transport accessible is overly complicated and fragmented and needs to adapt to changing uses of transport. This prevents both operators and travellers readily understanding rights and obligations, and makes redress harder to …
Gov response: 28. The Department accepts the need to look again at the legislative framework for accessibility in transport. The inquiry has highlighted the complex nature of the legislative framework that has grown over the years and …
Accepted
#2 — Designate a lead department for marine governance and policy coordination by January 2026.
Recommendation: Given the lack of coordination, we recommend that one department must act as the lead authority for marine governance and the coordination of marine policy. This department should be responsible for engaging with other departments and bodies, including The Crown …
Gov response: It is agreed that Government should support the needs of different marine sectors while ensuring the protection of marine nature and sustainable use of the marine environment. The Department for Environment, Food and Rural Affairs …
Position Not Stated
#1 — Blurred responsibilities and poor coordination undermine effective marine governance and accountability.
Recommendation: Whilst balancing economic and environmental demands is important, it is critical to ensure a balance between climate action and nature recovery, particularly in enabling offshore renewable energy developments to meet net zero targets without compromising marine biodiversity. Achieving sustainable marine …
Gov response: The Government therefore partially agrees with this recommendation. It is agreed that Government should support the needs of different marine sectors while ensuring the protection of marine nature and sustainable use of the marine environment. …
Response Not Attributed
#33 — Government's fragmented cloud buying approach limits potential commercial leverage and benefits
Recommendation: Government has made attempts to co–ordinate in order to gain benefits from its scale. GCF has signed agreements with the major cloud providers which allow them to treat the public sector as a single customer for the purposes of determining …
Gov response: 6.1 The government agrees with the Committee’s recommendation. Target implementation date: December 2025 6.2 The Commercial Operating model is evolving to consider how to facilitate the delivery of the functional standards for commercial and digital …
Accepted
#26 — Digital commercial expertise is unevenly distributed across government departments, lacking universal provision.
Recommendation: We observed that our predecessor Committee saw examples where departments made mistakes in designing and procuring digital programmes, particularly where legacy technology was involved. We were concerned that some larger departments are better served with digital skills than some of …
Gov response: 4.1 The government agrees with the committee’s recommendation. Target implementation dates: first phase by September 2025, second phase by March 2026, final phase to be confirmed. 4.2 Within the GCF there are already 500 individuals …
Accepted
#6 — Design a detailed commercial construct for cross-government digital technology procurement.
Recommendation: Government is underestimating how difficult it will be to consolidate its buying power centrally when procuring digital technology across government, in a way that will give it maximum leverage. Spending over £14 billion annually on digital technology suppliers gives government …
Gov response: The government agrees with the Committee’s recommendation. of the functional standards for commercial and digital and will be adjusted to reflect any proposed changes to the Commercial operating model under the Cabinet Office departmental transformation …
Accepted
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(52)— showing 50 strongest matches
Worthing Hospital
The trust must ensure that guidance documents have been reviewed and are up to date.
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
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
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
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
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
Yeovil District Hospital
The service must ensure that policies are up to date and reviewed in accordance with the review date.
Must Do
Warrington Hospital
The serviceshouldensureallpoiciesandproceduresareinplaceandreflectcurrentevidence-basedbestpractice andarefitforpurpose..
Should Do
Musgrove Park Hospital
The service must ensure that policies are available, up to date and reviewed in accordance with the review date.
Must Do
Frome Birth Centre (Frome Community Hospital)
The service should ensure that guidelines, standard operating procedures, and policies are up to date and reviewed regularly.
Should Do
Friarage 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
Must Do
Cambeck Close
We recommend the service follows best practice guidelines for having prescriber agreement on file for any changes in how medicines are administered from the instructions and the service's policy reflects the practice within the service.
Should Do
Cambeck Close
We have made a recommendation to ensure all current medicines advice is available for staff and the medicines policy reflects practices at the service.
Should Do
The Croft
Policies and procedures were out of date and did not provide guidance to staff in line with current legislation and best practice guidance.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensureastandardoperatingprocedureisavailableforstafftorefertowhenfentanylisdrawnupbystaff.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldconsiderastandardoperatingprocedure(SOP)forpatientsontheambulatorypathwaywithclearguidancetofollow.
Should Do
Leighton Hospital
The service should ensure that it implements a standard operating guideline for managing the telephone triage service in line with the most recent national guidance.
Should Do
King George Hospital
The service should remove signage that references older pathways or formerservice provision arrangements.
Should Do
University Hospital North Durham
The service must ensure that systems and processes for maternity triage are conducted in accordance with national guidance and embedded, so to deliver a safe service.
Must Do
Darlington Memorial Hospital
The service must ensure that systems and processes for maternity triage are conducted in accordance with national guidance and embedded, so to deliver a safe service.
Must Do
Private Ultrasound Scan
The service must ensure policies are comprehensive and reflect current legislation and best practice guidelines in order to give staff guidance for decision making.
Must Do
Royal Victoria Infirmary
The service should ensure the guidance within their PPH policy is clear about defining and grading maternal blood loss in accordance with national guidance.
Should Do
Leighton Hospital
The service must ensure it implements a standard operating procedure for timely second emergency theatre provision at all times so that staff follow a reliable and standardised process to ensure compliance with the emergency caesarean response times to ensure women …
Must Do
The Newcastle Clinic
The service should have a system to ensure all polices, procedure and guidance documents are reviewed, are current and are in date.
Should Do
Personal Security Service
The provider should ensure their policies are reflecting suitable legislation, regulation, and other national guidance relevant to the service.
Should Do
Harley Street Private Practice Limited
The service should ensure all the policies were version controlled and dated.
Should Do
Bradley Street
The servicemustreviewtheirpoliciesforrelevancetotheservicecontextandensurereviewdatesareappropriatelyidentified.
Must Do
Baby Bump Limited
The service should ensure all service policies are relevant for the service being provided.
Should Do
Ashton Lollipop
The service must review their policies for relevance to the service context and ensure review dates are appropriately identified.
Must Do
Acorn Hove
We recommend the provider consider current guidance on PRN protocols and take action to update their practice accordingly.
Should Do
The Croft
Neither the registered provider or registered manager had a good understanding of current guidance and legislation in managing health and social care services.
Should Do
Unit 4 Cornishway Industrial Estate
Review policies and standard operating procedures to determine I they reflect the service delivered and monitor performance against any policies
Should Do
The Withins
The provider should consult current guidance on rehabilitation support models to ensure a clear evidence-based structure is followed.
Should Do
My Homecare Peterborough
We recommend the provider seek professional support in the writing of PRN protocols.
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)
Scottish Fatal Accident Inquiries(16)
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 …
Jan 2012
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.
Jul 2013
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
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
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
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