Patient dignity and privacy
Failure to ensure suitable arrangements are in place to consider and respect the dignity, privacy, and independence of people using care services.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
98 inquiry recs
14 PFD reports
24 committee recs
17 HSSIB recs
261 CQC actions
3 PPO recs
84 IMB recs
1 IMB report
2 Scottish FAIs
2 Article 2 learning points
18 detention investigation recs
52 DHR recs
147 PHSO decisions
268 LGO/SPSO decisions
8 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(98)— showing 50 strongest matches
89 — Sensitive handling of persons rescued from accidents
Recommendation: Further consideration should be given to the sensitive handling of persons rescued from accidents including whether they should be sent onward by train (para 2.14).
Unknown
75 — Time and privacy to reflect
Recommendation: Ensuring relatives have sufficient time, privacy and support to reflect upon the request for consent to an HPM or the retention of organs following a CPM or an HPM.
Unknown
112 — Seek consents before interviewing
Recommendation: The consents of parents and of children where of a maturity to give consent should be sought prior to investigative interviewing being undertaken (17.51).
Unknown
106 — Child's choice of doctor's sex
Recommendation: A child should be able to choose whether the examination is conducted by a female or a male doctor (17.44).
Unknown
R85 — RQIA communication with patients
Recommendation: RQIA needs to spend proportionately more time talking to patients/residents, and its staff need to be trained in specific communication techniques such as Makaton and Talking Mats.
No response yet
P2-56 — Unlicensed body stores follow same standards
Recommendation: Where local authorities provide an unlicensed body store, they should do so in line with this Report's recommendations to local authority providers of licensed mortuaries.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-51 — Local authority biennial audits and peer review
Recommendation: The mortuary service must be reviewed by professional auditors at least biennially, with the results of the audit reported to a formal committee regardless of the level of assurance. Local authorities must arrange a peer review of the mortuary service …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-50 — Local authority mortuary as regulated service
Recommendation: The mortuary service must be treated in the same way as other regulatory services within local authority reporting structures: The mortuary must be visible to scrutiny at the relevant statutory committee, with regular reporting. Key performance indicators must be identified …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-49 — Local authority DI management and oversight review
Recommendation: There must be a review of the management and oversight arrangements for the mortuary service, taking into consideration who is appointed as the Designated Individual, their direct contact with the mortuary, level of influence within the local authority, and attendance …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-48 — Local authority annual SOP and HTA audits
Recommendation: There must be audits of the mortuary Standard Operating Procedures and compliance with Human Tissue Authority requirements, undertaken annually as a minimum, with a clear record of authorisation by the Designated Individual, head of service or equivalent. Audits of staff …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-47 — Local authority security breach investigation
Recommendation: There must be an investigation into the root cause of each security breach. Each incident, the investigation and action plan must be reported to director level within the local authority as a minimum. Serious security breaches must also be reported …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-45 — Local authority single security SOP
Recommendation: All policies and procedures in relation to the security of the mortuary must be accurately and comprehensively reflected in a single security Standard Operating Procedure.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-44 — Local authority incident response SOPs
Recommendation: Arrangements for responding to incidents of unauthorised access must be reviewed and incorporated into Standard Operating Procedures.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-43 — Local authority CCTV installation
Recommendation: CCTV must be installed inside the mortuary facing all doors and access points, the reception area and the doors of all fridges containing deceased people, including where these are accessible from within the post-mortem room. Local authorities must put appropriate …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-42 — Lock fridges and freezers at all times
Recommendation: Fridges and freezers containing deceased people must be locked at all times, with appropriate key security in place.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-41 — No reliance on keys/keypads alone
Recommendation: There must be no reliance on keys and keypad codes alone to secure access to the mortuary.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-40 — Local authority strategic security review
Recommendation: Immediate steps must be taken to commission a specialist strategic review of the systems in place to protect the deceased, which should include a detailed risk assessment of the potential breaches of security that could occur. The review should include …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-39 — Local authority security audits
Recommendation: Routine and regular audits of security must be conducted, encompassing both access to and exit from the mortuary and movement within it, including the post-mortem room. Access data must be reconciled against CCTV footage. Audits must be reported to the …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-38 — Local authority lone working review
Recommendation: Where mortuary staff are permitted to work alone in the mortuary, there should be a review of lone working policies, including consideration of activities involving direct handling of the deceased, alongside mitigations that can be put in place to safeguard …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-37 — Local authority visitor supervision
Recommendation: Where people other than mortuary staff are visiting the mortuary during working hours, for example contractors, cleaners and other visitors: Access must be limited to specific areas required for the purposes of their work or visit. They must be supervised …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-36 — Local authority individualised access controls
Recommendation: Where unsupervised access is permitted for a legitimate and unavoidable purpose, there should be individualised electronic access controls to enter the mortuary and restrict access to specific areas of the mortuary, such as the post-mortem room. There should be a …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-35 — Local authority mortuary access review
Recommendation: There should be a process to routinely review who is permitted to access the mortuary unsupervised.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-33 — Ambulance photography policies
Recommendation: Every NHS ambulance service must put policies in place regarding taking photographs of deceased patients, including any circumstances in which this may be required, and ensure that ambulance staff are aware of these and comply with them.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to DHSC setting out the work they are doing to implement recommendations 31 to 33. This includes discussing with ambulance service leads to ensure all ambulance …
Accepted
P2-32 — Ambulance policies on deceased security and dignity
Recommendation: NHS ambulance services should also have policies regarding the security and dignity of the deceased, including when the deceased should be covered and/or secured. NHS England should monitor that such policies are in place.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to DHSC setting out the work they are doing to implement recommendations 31 to 33. This includes discussing with ambulance service leads to ensure all ambulance …
Accepted
P2-31 — Ambulance policy on crew position with deceased
Recommendation: Every NHS ambulance service should have a policy setting out where ambulance crew members should sit when conveying deceased patients. This should include reference to the risk of abuse of deceased patients, as well as training requirements.
Gov response: The Association of Ambulance Chief Executives (AACE) has written to DHSC setting out the work they are doing to implement recommendations 31 to 33. This includes discussing with ambulance service leads to ensure all ambulance …
Accepted
P2-27 — Hospice security and access controls
Recommendation: Hospices that care for deceased people on their premises should: introduce auditable access control of the area where deceased people are kept; have Standard Operating Procedures regarding the care of deceased people, including security of and access to the areas …
Gov response: DHSC has worked with Hospice UK to ask its clinical leaders group network to urgently review their clinical practices against the recommendations. Hospice UK has already updated its Care After Death guidance for the hospice …
Accepted
P2-24 — Anatomical education security and dignity policies
Recommendation: All organisations providing anatomical education and training using donors should make sure that policies and procedures are in place to ensure the security and dignity of donors. These should include: security and access policies and the auditing of security and …
Gov response: For the remaining 21 recommendations, these remain under consideration.
Response Unclear
P2-23 — Independent sector accompanied access to deceased
Recommendation: Independent sector healthcare providers should ensure that only people who have a legitimate reason to access a room that contains a deceased patient do so, even if they are staff members, and that they are always accompanied.
Gov response: DHSC officials have met twice with the Independent Healthcare Provider Network (IHPN), which engaged with its members in September 2025. Members have confirmed they have taken action on the report. IHPN is now considering how …
Accepted
P2-22 — Independent sector SOPs for deceased patients
Recommendation: Independent sector healthcare providers should ensure that there are Standard Operating Procedures and policies in place to protect the security and dignity of any patients that die under their care. Wherever possible, deceased patients' rooms should be kept locked. Providers …
Gov response: DHSC officials have met twice with the Independent Healthcare Provider Network (IHPN), which engaged with its members in September 2025. Members have confirmed they have taken action on the report. IHPN is now considering how …
Accepted
P2-21 — NHS England incorporate deceased in safeguarding framework
Recommendation: NHS England should formally incorporate the safeguarding of deceased people into its safeguarding framework for NHS trusts.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-20 — Chief Nurse responsibility for deceased safeguarding
Recommendation: The remit of the Chief Nurse in NHS trusts should explicitly include executive responsibility for safeguarding the security and dignity of deceased people in NHS mortuaries and body stores.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-5 — Operational barriers including device restrictions
Recommendation: All NHS trusts should consider putting in place systemic operational barriers that prevent the security and dignity of deceased people being compromised. An example of this would be implementation of a rule that prevents electronic devices such as phones or …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-4 — End shared swipe cards
Recommendation: The practice of using shared electronic swipe cards for specific staff groups should cease immediately.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P2-3 — Audit access data for deceased storage
Recommendation: All NHS trusts should routinely audit the access data of all facilities used to store deceased people.
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
BAHA-25 — Restriction on Waking CPERS
Recommendation: In line with Recommendation 11 above, the tactical questioning and interrogation policies need to make clear that it is not permissible to deliberately keep prisoners awake, even for short periods, merely because they may shortly face tactical questioning or interrogation. …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
BAHA-13 — Segregation and Sight Deprivation
Recommendation: In dealing with segregation, JDP 1-10 should make clear that sight deprivation should not be used as a means of segregating CPERS to prevent them communicating with each other.
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
104 — Sheriff may authorise medical examination
Recommendation: The Sheriff should be empowered to authorise a child to be taken for a medical examination (17.41), although the carrying out of the examination should not proceed if the child refuses to be examined (17.42).
Unknown
P2-2 — CCTV in all NHS mortuaries
Recommendation: All NHS trusts should install CCTV inside the mortuary, with cameras facing all doors and access points, the reception area and the doors of body fridges, while maintaining the security and dignity of deceased people by implementing the appropriate safeguards. …
Gov response: The government has agreed to accept in principle 43 recommendations subject to further work to determine the full impact of these recommendations.
Accepted in part
P1-17 — Deceased treated with same dignity as patients
Recommendation: Maidstone and Tunbridge Wells NHS Trust must treat the deceased with the same due regard to dignity and safeguarding as it does its other patients.
Gov response: The Trust now complies with this recommendation in full on the following basis: • A definition of “Safeguarding” has been developed by the Trust’s Chief Nurse that can apply to this context, given that the …
Accepted
P1-9 — CCTV in mortuary including post-mortem room
Recommendation: Maidstone and Tunbridge Wells NHS Trust must install CCTV cameras in the mortuary, including the post-mortem room, to monitor the security of the deceased and safeguard their privacy and dignity.
Gov response: The Trust now complies with this recommendation in full on the following basis: • CCTV cameras were initially installed in the Trust’s mortuaries in the spring of 2020 (the installation at Maidstone Hospital was completed …
Accepted
AS-7 — Strip-Search Safeguards
Recommendation: Appropriate measures should be taken to ensure that minimum safeguards are in place where a detainee is to be strip-searched. These include informing a detainee as to the necessity for the strip-search and requesting his/her co-operation. Those conducting a strip-search …
Gov response: Sir Thayne Forbes has made just nine recommendations, and he acknowledges the progress that the Ministry has made since 2004 to improve all aspects of the prisoner-handling system—from policy and doctrine to unit-level instructions and …
Accepted in part
3 — Guidance on control of patients' money
Recommendation: The Department are now preparing new guidance on the control of patients’ money which will avoid the retention of large sums at ward level. We welcome this but hope that nurses will be able to retain and develop their therapeutic …
Unknown
83 — Translation and accessibility services
Recommendation: Accessing translation/interpreting services including services for people with hearing or visual impairment and providing appropriate written/taped information.
Unknown
80 — Practical help for relatives
Recommendation: Assisting relatives in the following practical matters: – collecting the deceased’s personal belongings and arranging return to relatives; – ensuring provision of certificate of death and the formal notice; – explaining the procedure to register the death; – providing support …
Unknown
77 — Meetings with clinician and pathologist
Recommendation: Facilitating meetings between parents, clinician and pathologist as appropriate.
Unknown
74 — Explain consent after Coroner examination
Recommendation: Explaining that consent is necessary for the retention of organs following a Coroner’s post mortem examination (CPM) and that the consent must be obtained before the CPM is undertaken.
Unknown
73 — Explain need for hospital consent
Recommendation: Explaining the need for consent to carry out a hospital post mortem examination (HPM) and the retention of organs.
Unknown
72 — Explain reasons for post mortem
Recommendation: Ensuring that relatives have a full explanation of the reasons for post mortem examination including therapeutic, medical education and research.
Unknown
71 — Meeting with treating clinician
Recommendation: Encouraging a meeting between relatives and the treating clinician to explain the clinical circumstances of death and if requested arranging and attending the meeting.
Unknown
70 — Meeting with those present at death
Recommendation: Arranging and attending a meeting for relatives with anyone who was present at the death if requested.
Unknown
Prevention of Future Deaths reports(14)
Anthony Brian Flynn
Concerns: The coroner identified insufficient training for prison officers on escorting prisoners during hospital visits and a lack of awareness among clinicians about their power to request restraint removal. This was highlighted by a sick prisoner being restrained during examination and a subsequent uninvestigated clinician complaint.
Response (Sodexo): • Sodexo stated it had reviewed training for prison officers regarding hospital escorts and procedures for making clinicians aware of their powers. • Sodexo confirmed it had prepared an escort/bedwatch … (AI summary)
Overdue
Mrs Care
Concerns: The coroner noted concerns that extensive bruising sustained by Mrs Care during her hospital stay, which contributed to her death, could not be explained. There was no evidence to determine how the trauma occurred, despite speculation about hoist use.
Overdue
Barbara Cooke
Concerns: Inadequate staffing at Waxham House impacted timely personal care and dignity, alongside insufficient protocols for chasing district nurses. St Mary's Hospital lacked systems for recording and reporting safeguarding alerts for inpatients.
Overdue
Billie Lord
Concerns: The coroner noted that three-bedded dormitory accommodation at the Campbell Centre was inappropriate for mental health patients, causing additional stress, and recommended a review of the facilities to meet modern standards.
Response (Milton Keynes Clinical Commissioning Group): • CNWL Mental Health Trust is commissioning a study to assess the feasibility of creating a new inpatient campus in Milton Keynes. • The Milton Keynes CCG stated it offers … (AI summary)
Responded
Alice Dixon
Concerns: Concerns were raised regarding inadequate support and communication during the consent process for a vulnerable patient in the radiography suite, coupled with insufficient sharing of her specific vulnerabilities. The physical setup of the suite also impeded effective patient monitoring during the scan.
Overdue
Agnes Sansom
Concerns: Patient record systems do not ensure timely communication of urgent information to relevant staff, and vulnerable patients are obliged to share walking aids on hospital wards.
Response (County Durham and Darlington NHS): • Physiotherapists now record changes in patient mobility or required interventions in the Nervecentre mobility gallery. • A buffer stock of walking aids has been implemented in hospitals to ensure … (AI summary)
Responded
Mavis Lawrence
Concerns: The coroner raised concerns regarding insufficient checks, documentation, and assessment of pressure areas and wounds. Further issues included a pressure mattress being turned off, a lack of staff escalation, and inadequate involvement of GPs and Tissue Viability Nurses.
Response (Midlands Partnership NHS Foundation Trust): • The Trust relaunched an updated pain assessment tool with all clinical staff in August 2020. • A new Community Nursing Assessment document has been introduced to document holistic assessments … (AI summary)
Overdue
Robert Walaszkowski
Concerns: The coroner identified concerns regarding Patient Transport UK Ltd's practice of placing detained mental health patients on the floor of secure vans without restraints, especially for medically vulnerable individuals. There was also a lack of incident review and staff reconsideration of vehicle suitability.
Overdue
George Griffiths
Concerns: The coroner noted footwear was not removed during a prolonged emergency department stay, leading to a necrotic toe without appropriate management. Concerns were also raised about a lack of preventative pressure area care, delayed reassessment, and non-mandatory pressure care training within the Trust.
Response (Wye Valley NHS Trust): • The Trust introduced a senior nurse care review in the Emergency Department for patients with extended stays and is updating its pressure area care policy and standard operating procedure … (AI summary)
Responded
Ronald Ashdown
Concerns: The coroner noted inadequate personal care was provided to RA in hospital, evidenced by photographic findings upon his return to the nursing home. The subsequent NHS Trust investigation was significantly flawed, failing to incorporate critical evidence.
Response (Mid and South Essex NHS Foundation Trust 1): • The Trust provided an updated action plan detailing steps taken and planned, with most actions completed and remaining actions due by 30 September 2023. • The Trust amended its … (AI summary)
Responded
Kim Stroud
Concerns: The coroner noted non-compliance with medication administration policies, with tablets left unsupervised for a patient with delirium. Additionally, the patient was repeatedly found unhygienic, requiring family members to assist with cleaning and changing.
Response (The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust): • The Trust apologised to the family for the standard of care provided and noted that new staff on relevant wards have undertaken or are scheduled to attend a 'Caring … (AI summary)
Responded
Marina Young
Concerns: A&E management lacked timely alerts for prolonged patient stays and adequate assessment of complex care needs. Concerns also related to insufficient nurse knowledge of basic asthma assessments and a failure to escalate problems to senior nursing staff.
Response (Lancashire Teaching Hospitals NHS Trust): • The Trust has formulated and attached an action plan addressing the concerns raised. • The Trust will progress the actions outlined in the plan and provide further updates. • … (AI summary)
Responded
Tamara Davis
Concerns: The coroner raised concerns about the ongoing practice of treating patients in undesignated hospital corridors when the Emergency Department exceeds capacity, leading to a lack of privacy, toilet facilities, and confidentiality for patients.
Response (NHS England): • NHS England published principles for providing safe and good quality care in temporary escalation spaces. • Operational planning guidance was issued to systems to improve patient flow, productivity, and … (AI summary)
Response (University Hospitals Sussex NHS Foundation Trust): • The Trust employed an Operational Flow Improvement Manager to lead a programme aimed at reducing admissions, optimising hospital flow, and smoothing discharge pathways. • A Continuous Flow Model commenced … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care stated its officials made enquiries with NHS England regarding the concerns. • An independent investigation into NHS performance was ordered, its report … (AI summary)
Responded
Iris Carter
Concerns: The coroner noted that a Grade 4 pressure sore, likely present prior to discharge from Queen Elizabeth Hospital, was not properly inspected for or adequately documented in patient notes during the hospital admission.
Response (University Hospitals Birmingham NHS Foundation Trust): • The Trust provided feedback on omissions in care to the wider nursing team, updated the pressure ulcer prevention ward information board, and discussed Mrs Carter’s case at the daily … (AI summary)
Responded
Select committee recommendations(24)
#9 —
Recommendation: The risks posed to vulnerable individuals by Covid-19 make more urgent the necessity of a complete end to room sharing by unrelated adults. While the first peak of infection has passed in some parts of the UK, there continues to …
Response attribution not verified
#8 —
Recommendation: Our predecessor Committee recommended that shared accommodation should be phased out across the estate as a whole. While we welcome the progress towards ending this practice, we are extremely disappointed that the Home Office did not take the opportunity of …
Response attribution not verified
#6 —
Recommendation: Vulnerable people such as pregnant women, victims of abuse and people with PTSD should never be placed in accommodation in which they have to share a room with an unrelated adult, nor should they be required to use shared bathroom/toilet …
Response attribution not verified
#24 — Cease using 'benign' and reprioritise chronic reproductive conditions like endometriosis for surgical treatment
Recommendation: NHS England should cease to use the term benign in relation to reproductive ill health. The NHS should work with stakeholders to develop a way to describe these conditions that more accurately reflects the serious impact they can have on …
Response attribution not verified
#23 — Benign gynaecology' terminology downplays reproductive health conditions, risking treatment de-prioritisation
Recommendation: The use of terminology such as ‘benign gynaecology’ downplays the impact of reproductive health conditions and risks de-prioritising them for treatment that could significantly improve patients’ health and lives.
Response attribution not verified
#22 — Implement policies ensuring separate spaces for reproductive health and obstetrics patients during investigations/treatment
Recommendation: NHS England should implement policies to ensure there are separate spaces for patients undergoing investigations or treatment for reproductive health conditions and obstetrics patients. (Paragraph 91) Waiting lists
Response attribution not verified
#17 — Enforce informed consent and halt painful gynaecological procedures lacking adequate pain relief.
Recommendation: The NHS must do more to monitor and enforce protocols governing procedures such hysteroscopy, IUD fitting and cervical screening and ensure that they are underpinned by informed consent and are trauma-informed. A risk assessment that allows a patient to make …
Response attribution not verified
#16 — NHS fails patients during routine reproductive procedures, neglecting duty of care and pain management.
Recommendation: The NHS is failing many patients who undergo routine reproductive healthcare procedures such as hysteroscopy, IUD fitting and cervical screening. In too many cases, we find that a duty of care from gynaecologists and other medical practitioners is absent. Women …
Response attribution not verified
#14 — Healthcare practitioners insufficiently understand reproductive health treatment options and their impact on patients.
Recommendation: Healthcare practitioners lack sufficient understanding of the range and suitability of treatment options available to treat reproductive health conditions. Too often conditions are viewed through the prism of fertility which, while a necessary consideration, should not be the only factor …
Response attribution not verified
#10 — Medical misogyny and racism lead to dismissed pain in women's reproductive healthcare.
Recommendation: There is a clear lack of awareness and understanding of women’s reproductive health conditions among primary healthcare practitioners, particularly when those conditions occur in young women and girls. Women are finding their symptoms normalised and their pain dismissed, with an …
Response attribution not verified
#46 — Sick leave inadequate for miscarriage support, lacking confidentiality, dignity, and sufficient pay
Recommendation: conclusion Sick leave is an inappropriate and inadequate form of employer support in the aftermath of a miscarriage or pregnancy loss. It does not afford women adequate confidentiality or dignity and puts them at high risk of employment discrimination. The …
Response attribution not verified
#70 — Strictly limit handcuff use for child transport and ensure provider accountability with Ofsted.
Recommendation: The Department for Education must act to strictly limit the use of handcuffs to those cases where it is otherwise unavoidable or necessary for the child’s own safety, and work with Ofsted to ensure that local authorities and transport providers …
Response attribution not verified
#30 — Reduce visibility of security guards in Jobcentres, ensuring a more welcoming entry experience.
Recommendation: Jobseekers are not criminals and shouldn’t be greeted at Jobcentres by security guards. DWP should make security guards much less visible in Jobcentres, with a more welcoming presence when people enter. (Recommendation, Paragraph 133)
Response attribution not verified
#27 — Jobcentre environments often lack accessibility and welcome, undermining efforts to support claimants.
Recommendation: Jobcentres are not places that people want to go to. They are often run-down and lack basic facilities, including accessibility features. An intimidating security presence can create additional barriers for some. It will be important that when people walk through …
Response attribution not verified
#19 — Create new Establishment Payment for community pharmacies to develop patient consultation spaces.
Recommendation: We recommend the creation of a new “Establishment Payment” to be paid to eligible community pharmacies to support the development of consultation spaces for patients. This funding should be targeted at pharmacies that are the most reliant on NHS work …
Response attribution not verified
#18 — Support for smaller pharmacies is needed to provide private clinical consultation spaces.
Recommendation: Community pharmacies offering clinical services must have private, comfortable spaces in which to see patients. We acknowledge the minister’s comments around pharmacies being private businesses, but they are ultimately expected to provide NHS services. As the expanding availability of clinical …
Response attribution not verified
#9 — FGM survivors experience shame in healthcare due to inadequate cultural sensitivity training.
Recommendation: Evidence suggests some FGM survivors are experiencing shame or humiliation in healthcare settings, reducing the likelihood of them engaging further with healthcare services essential to their physical and mental wellbeing. Training for midwives and healthcare professionals is not mandatory and …
Response attribution not verified
#11 — Implement urgent NHS training challenging racial biases to improve reproductive healthcare in primary care.
Recommendation: The NHS needs to urgently implement a training programme to improve the experience of treatment and diagnosis in primary care for women, girls, trans and non-binary people with reproductive ill health. Improving early diagnosis, including through the provision of follow …
Response attribution not verified
#3 —
Recommendation: There is a risk that the new Hospital 2.0 design might not benefit some patients or may add cost. The Hospital 2.0 design was originally due to be ready in December 2023 but, following multiple delays, the Department will not …
Response attribution not verified
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#16 —
Recommendation: The Department assumes that these single bedrooms will be more efficient, reducing the average patient length of stay by 0.5% annually, plus an additional one-off reduction of 8% to 10% when the new hospital schemes open. However, some research has …
Response attribution not verified
#2 —
Recommendation: Notwithstanding the actions taken to date, we recommend that NHS England & Improvement review, as a matter of priority, the directions given to NHS Trusts about how to communicate with patients about the progress of their treatment and important medical …
Response attribution not verified
#9 —
Recommendation: We acknowledge that our direct responsibility is to scrutinise the work of the Northern Ireland Office of the UK Government rather than The Executive Office of the Northern Ireland Executive, but many of the findings of our report bear upon …
Response status not verified
HSSIB safety recommendations(17)
Healthcare provision in prisons: continuity of care
HSSIB recommends that HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood …
Safety Recommendation
Unplanned delayed removal of ureteric stents
It is recommended that the British Association of Urological Surgeons works with the Patient Information Forum to review its stent patient information leaflet. This should include accessibility and clinical considerations, especially with regards to side effects and complications, and advice …
Safety Recommendation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Interpretation services The review identified that family members do provide translation support when interpretation services cannot be provided by the local maternity service, even though this is not in line with national guidance. However, during the first wave of the …
Learning Prompt
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
HSIB recommends that NHS England and NHS Improvement develop minimum operating standards for interpretation services in maternity care which will include a communication risk assessment.
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that NHS England, working with relevant stakeholders, develops guiding principles for providers of mental health inpatient care to support local decision making when accommodating patients, including patients who are transgender and non-binary. This is to ensure a provider’s …
Safety Recommendation
Patient care in temporary care environments
Does your organisation ensure that patients in temporary care environments are regularly engaged with to ensure that they have food, water, are comfortable, understand what is happening to them and what the plan is going forward?
Learning Prompt
Patient care in temporary care environments
Does your organisation provide information to patients about the use of temporary care environments and to inform them that any patient may be placed in one if there is a clinical need to provide a space for other patients?
Learning Prompt
Healthcare provision in prisons
HSSIB recommends that HM Prison and Probation Service standardises the approach to the provision of prison officer escorts for outpatient appointments to protect the dignity of patients and reduce variability of escort slots. This will assist in reducing the likelihood …
Safety Recommendation
Clinical investigation booking systems failures: written communications in community languages — HSSIB
It may be beneficial for NHS care providers to explore options for the translation of written appointment communications, including pre-attendance guidance, for patients whose preferred written language is not English.
Safety Observation
Investigation report: Mental health inpatient settings - out of area placements
Mental health inpatient services can improve patient safety by offering advocacy to all mental health inpatients at the point of admission, and ensuring that the patient’s decision about whether or not to have an advocate is continually reviewed as their …
Safety Observation
Investigation report: Mental health inpatient settings - out of area placements
HSSIB recommends that the Department of Health and Social Care includes the documenting of patient, family and carers’ wishes and preferences within the Mental Health Bill. This will ensure all patient, family and carer voices are considered in decisions relating …
Safety Recommendation
Patient care in temporary care environments
Has your organisation made adaptations to temporary care environment spaces that include having essential equipment nearby? For example, emergency call bells, communication systems, personal call bells, spaces for personal care and invasive treatments.
Learning Prompt
Healthcare provision in prisons
HSSIB recommends that NHS England/Department of Health and Social Care ensures that the General Medical Services registration process, for patients in prison, is designed using informed consent principles, providing patients sufficient time, advice and support to understand what registration means …
Safety Recommendation
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that NHS England/Department of Health and Social Care ensures that the General Medical Services registration process, for patients in prison, is designed using informed consent principles, providing patients sufficient time, advice and support to understand what registration means …
Safety Recommendation
Management of chronic asthma in children aged 16 years and under
There is now an alternative vaccine for those children whose parents refuse the nasal flu vaccine due to the porcine gelatine content. Children in a higher risk group are eligible to receive an injectable vaccine as an alternative to the …
Safety Action
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Telephone triage Difficulties in communication were identified, relating to the availability and presentation of clinical records, documentation and communication of information from triage calls, and availability of interpretors particularly in urgent circumstances. The usual reliance on family members to provide …
Learning Prompt
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
Health and care organisations can improve patient safety by allocating a point of contact for patients and/or their carers when people are discharged from services out of normal working hours. This will ensure patients and their carers are able to …
Safety Observation
NCEPOD recommendations(5)
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
CQC inspection actions(261)— showing 50 strongest matches
William Harvey Hospital
The trust must ensure patients are always treated with dignity and respect, including during medical and clinical assessments when in overcrowded areas.
Must Do
William Harvey Hospital
The trust must ensure that patients are treated with dignity and respect at all times, including during medical and clinical assessments when in overcrowded areas.
Must Do
Westmorland General Hospital
The trust should ensure that privacy and confidentiality is maintained for patients when sharing personal information.
Should Do
Westmorland General Hospital
The trust should ensure that visible information about requesting a chaperone is available to patients attending the centre.
Should Do
Westmorland General Hospital
The service must ensure that privacy and dignity of patients is maintained, particularly when patients are in non-designated cubicle areas.
Must Do
University Hospital of Hartlepool
The service should ensure that there are appropriate facilities and reasonable adjustments made for children and young people and their families who are being treated on adult wards to make them comfortable.
Should Do
The York Hospital
The trust should ensure that patient information on whiteboards remains confidential throughout the service and is not located in areas where the general public can see it.
Should Do
The York Hospital
The trust must ensure that attendance to patient ‘fundamental care needs’ are met, including getting enough help to wash or keep clean and to eat meals, as well as being able to get help from staff when needed.
Must Do
The York Hospital
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients and protects their privacy and dignity.
Must Do
The York Hospital
The trust must ensure that mixed sex breaches where men and women share the same area did not occur.
Must Do
The York Hospital
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients, protects their privacy and dignity, and ensures staff can offer them emotional support.
Must Do
The Royal Oldham Hospital
The trust must ensure the service maintains patients’ privacy and dignity at all times on the corridors when undertaking confidential conversations, assessments and providing treatment.
Must Do
The Princess Royal Hospital
The trust should ensure the privacy and dignity of all patients is maintained at all times.
Should Do
The Princess Royal Hospital
The trust should ensure the mortuary viewing glass is fit for purpose.
Should Do
The Princess Royal Hospital
The service should ensure consideration is given to separating people of different genders in escalation areas.
Should Do
The Princess Royal Hospital
The service should ensure patients have reasonable access to toilet facilities and showers.
Should Do
The Princess Royal Hospital
The trust must ensure that patients within all areas of the emergency department consistently have their right to privacy respected.
Must Do
The Princess Royal Hospital
The trust must ensure they adhere to the policies in place around mixed sex breaches.
Must Do
The Princess Royal Hospital
The service must ensure that service users are treated with dignity and respect.
Must Do
The County Hospital
The trust should ensure the privacy and dignity of all patients is maintained at all times.
Should Do
The County Hospital
The service should ensure improved arrangements for offering food and drink to patients who have been waiting a long time to be seen, transferred or discharged.
Should Do
Scarborough Hospital
The trust should ensure that patient information on whiteboards remains confidential throughout the service and is not located in areas where the general public can see it.
Should Do
Scarborough Hospital
The trust must ensure that attendance to patient ‘fundamental care needs’ are met, including getting enough help to wash or keep clean and to eat meals, as well as being able to get help from staff when needed.
Must Do
Scarborough Hospital
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients and protects their privacy and dignity.
Must Do
Scarborough Hospital
The trust must ensure that mixed sex breaches where men and women share the same area did not occur.
Must Do
Scarborough Hospital
The service must ensure their new ED environment does not compromise the fundamental standards of care staff can provide to patients, protects their privacy and dignity, and ensures staff can offer them emotional support.
Must Do
Salford Royal Hospital
The service should ensure that ward moves are not completed after 8pm, unless clinically required, to avoid disturbing rest and disorientating patients.
Should Do
Salford Royal Hospital
The service should ensure that mixed sex breaches are avoided on medical wards.
Should Do
Salford Royal Hospital
The service must ensure patients are treated with dignity and respect and ensure the privacy for patients is maintained, particularly for those cared for on the corridor.
Must Do
Royal Sussex County Hospital
The trust should ensure they monitor call bell wait times to ensure patients are not left for long periods of time when needing support from staff.
Should Do
Royal Sussex County Hospital
The trust should ensure that patients’ privacy and dignity are supported when being moved by following surgery.
Should Do
Royal Shrewsbury Hospital
The trust should ensure the privacy and dignity of all patients is maintained at all times.
Should Do
Royal Shrewsbury Hospital
The service should ensure consideration is given to separating people of different genders in escalation areas.
Should Do
Royal Shrewsbury Hospital
The trust must ensure that patients within all areas of the emergency department consistently have their right to privacy respected.
Must Do
Royal Shrewsbury Hospital
The trust must ensure they adhere to the policies in place around mixed sex breaches.
Must Do
Royal Shrewsbury Hospital
The service must ensure that service users are treated with dignity and respect.
Must Do
Royal Preston Hospital
The trust should ensure that all conversations with patients, and their families take place in an environment where they are not overheard
Should Do
Royal Preston Hospital
The trust should continue to improve the provision of single sex washing facilities for patients.
Should Do
Royal Preston Hospital
The service should ensure that patient identifiable details are not displayed on public boards.
Should Do
Rochdale Infirmary
The service should ensure that ward moves are not completed after 8pm, unless clinically required, to avoid disturbing rest and disorientating patients.
Should Do
Rochdale Infirmary
The service should ensure that mixed sex breaches are avoided on medical wards.
Should Do
Rochdale Infirmary
The service must ensure patients are treated with dignity and respect and ensure the privacy for patients is maintained, particularly for those cared for on the corridor.
Must Do
Rawreth Court
People were not always treated with dignity and respect.
Must Do
Queen's Hospital
The service should consider making improvements to the children’s emergency department’s mental health rooms to protect the dignity and privacy of patients.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure patients are always treated with dignity and respect, including during medical and clinical assessments when in overcrowded areas.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that patients are treated with dignity and respect at all times, including during medical and clinical assessments when in overcrowded areas.
Must Do
Princess Royal Hospital
The hospital should act to reduce the number of mixed sex breaches.
Should Do
Pilgrim Hospital
The trust should consider discussing mixed sex accommodation with young people proactively rather than reactively.
Should Do
Peterborough City Hospital
The trust should consider ensuring the bereavement room is soundproof to improve the experience of bereaved women and families who have experienced a loss.
Should Do
Orpington Hospital
The trust should ensure that staff provide care and treatment in ways which have regard and respect for the individual needs of patients, and in a manner, which is not degrading.
Should Do
PPO death in custody recommendations(3)
The Head of Healthcare
The Head of Healthcare should ensure that, wherever possible, consultations and assessments with prisoners are carried out in private and if this cannot happen, the reason is clearly documented.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are reminded that during a medical emergency and in the event of a prisoner’s death, the conduct and language staff use should be professional and reflect the seriousness of the …
The Governor of Isle of Man Prison
The Governor should consider establishing a protocol with the Isle of Man Constabulary to ensure that following a death in custody the deceased’s body is moved back into their cell for dignity, if there is no suspicion of a crime.
IMB individual recommendations(84)— showing 50 strongest matches
London STHF (2024)
A solution needs to be found to give people waiting in the CWAs more privacy, and the CWA in T2 needs to be enlarged.
Home Office
Hewell (2022)
There should be capital investment to end the practice of men cell sharing, with an open toilet in the space where they are expected to sleep, eat and live; this would reduce friction between prisoners and increase prisoner respect and engagement with the regime. This is an inhumane practice.
Ministry of Justice
Noted
Downview (2023)
There are no privacy curtains in the consulting rooms in healthcare (section 6).
Governor / Director
North West and Midlands STHF (2025)
The Board is concerned at the practice of leaving detained people in the CWA, and recommends that they should always be afforded the dignity, privacy and relative comfort of being moved into the holding room where there are toilets and other facilities to help them rest while being detained (see section 5/Fair and humane treatment).
Home Office
Foston Hall (2023)
The medication dispensing hatch remains unfit for purpose, with prisoners queuing outside in all weathers and not being assured of privacy if the queue isn’t well-managed. When will this be addressed?
Governor / Director
Send (2024)
The Board is concerned about the practice of potentially using an escort chain or handcuff of a prisoner to an officer during a breast screening.
HMPPS
In Progress
London STHF (2024)
The Board has been asking for toilet seats in all terminal holding rooms for the last few years and we would like to see this issue finally resolved.
Other
Send (2025)
The Board would like to see a policy which states that the use of escort chains for prisoners during intimate medical examinations or confidential consultations outside the prison be the exception rather than the norm (6.1).
HMPPS
In Progress
North West and Midlands STHF (2025)
The Board is concerned that a holding room at Birmingham Airport has been decommissioned and turned into a storeroom. When the Family Room is cold and draughty, detained individuals have been moved into a small room, which compromises their comfort and wellbeing.
Home Office
Wormwood Scrubs (2020)
Can the use of escort chains at a local level be reviewed – in particular their use for very elderly or sick prisoners?
Governor / Director
Winchester (2021)
What is the prison service doing to hasten the upgrade to the healthcare bathroom and shower area which should be condemned? This work is very long overdue and the need for it was raised in our last two annual reports. (See section 6.3).
HMPPS
In Progress
Wandsworth (2021)
The lack of adequate kit was a recurrent issue. This included frequently reported shortages of kettles, bedding and clothing. The Board was also concerned about the number of complaints concerning the lack of privacy curtains in shared cells. What is being done to rectify this very unsatisfactory situation?
Governor / Director
Heathrow and City airports Short Term Holding Facilities (2021)
The Home Office should progress the provision of a shower in Terminal 5 to comply with the National Holding Room Standards.
Home Office
Scotland and Northern Ireland Short-Term Holding Facilities (2022)
We recommend that the bedroom accommodation is improved, thus affording appropriate sleeping accommodation and facilities for private time. The outcome would be the fair and humane detention of each detained person.
Governor / Director
London Heathrow and City Airports (2022)
[London Heathrow Airport Terminal 5] The Board repeats its recommendation that the Home Office should substantially improve the facilities for families and children in Terminal 5. These are currently excessively cramped, and they lack an integrated toilet, shower and baby-changing facilities. (See paragraphs 4.3.46 – 4.3.48)
Home Office
Styal (2023)
Accommodation remains a key issue in the prison, with particular regard to decency, disability and dignity, given the limited access to bathrooms and toilets, and the ongoing maintenance issues in the 17 residential houses. What consideration has been given to the option of competitive tendering for large scale maintenance and refurbishment projects to enable a more timely solution to these …
HMPPS
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The Board wishes to see target dates for the implementation and completion of work to provide safe and private facilities for women in Larne House RSTHF, as well as the upgrading of all bedrooms Larne House in line with the trail, re-equipped room.
Other
Humber (2023)
The Board repeats this view: that forcing men to share cell accommodation designed for single occupancy and which contains toilet and washing facilities with little or no privacy is neither decent nor fair. The requirement to insist on such use reflects poorly on HMPPS.
HMPPS
In Progress
Dartmoor (2023)
Currently 98 prisoners at HMP Dartmoor are being held in shared, cramped cells lacking furniture, originally designed to accommodate one person. The Independent Monitoring Board regards this as inhumane, unjust and unsustainable. For how long will the prison be asked to accommodate prisoners in these single cells, and can the Minister provide any assurance that there will be no further …
Ministry of Justice
Belmarsh (2023)
The phone in the communal area of HSU is near the desk used by staff which prevents prisoners from having their phone calls in private, could arrangements be made to improve soundproofing around HSU phone or move it away from the staff desk?
Governor / Director
Portland (2024)
What will the Minister do to increase funding to address overcrowding in the prison and eliminate doubling up in cells designed for one individual, impacting personal decency and privacy. Overcrowding also impacts the ability of the prison to transfer prisoners to other prisons that offer the training required to support their release.
Ministry of Justice
In Progress
North West and Midlands STHF (2024)
The Board is concerned at the practice of leaving detained persons in the Controlled Waiting Areas, and recommends that they should always be afforded the dignity, privacy and relative comfort of being moved into the Holding Room where there are toilets and other facilities to help them rest while being detained (see section 2.3.2.4).
Home Office
London STHF (2024)
The temperature problems in the holding rooms, both at London Heathrow and London City Airport, need to be resolved. The Board would like to see DCOs be given some form of control, either by being able to directly adjust the temperature or by asking someone to adjust the temperature at their request.
Other
Garth (2024)
The Board recommends that this situation [the very poor waiting facilities for prisoners in the healthcare department of the prison] is addressed as a priority. It is understood that improving this waiting area would require substantial funding and work but, after so many years of complaints, it is time that the problem is resolved.
HMPPS
Noted
Foston Hall (2024)
Prisoners continue to queue outside the medication dispensing hatch, whatever the weather, with no shelter. When will shelter be provided for them?
Governor / Director
South and East Short Term Holding Facilities (STHF) (2025)
The Board recommends where floor space is sufficient, such as at Gatwick North and South main holding rooms, that the adequate provision of sleeping mattresses should be reviewed, as noted in 5.1.
Home Office
South and East Short Term Holding Facilities (STHF) (2025)
The Board recommends that the Minister review the accommodation capacity, especially as noted in 4.3 and 5.1 at Luton and Stansted. There are an increasing number of people held overnight at the STHFs, which are not designed for overnight accommodation and, in some places, do not provide a dignified and humane space and where the only hot food available at …
Other
North West and Midlands STHF (2025)
We recommend that the bed capacity for women in increased. Bedroom 7 in Manchester RSTHF, which has been designated for their use, is on a corridor where all the male bedrooms and male showers and toilets are located. The risk of possible physical harm to, and abuse of, women in this location has, therefore increased, in the Board’s view. We …
Governor / Director
Durham (2025)
Yet again, the Board has raised concerns about the levels of overcrowding and its impact on the dignity of prisoners. Yet again, we have received answers offering no hope of improvement. When will the Minister actually resolve this issue? (5.1.1)
Ministry of Justice
In Progress
Winchester (2020)
Will the Governor endeavour to solve the problem of the exercise yard for vulnerable prisoners being overlooked by B and C wings (see section 4.4)?
Governor / Director
Exeter (2020)
Will the Prison Service review its quality assurance arrangements to improve the effectiveness of GFSL in providing an efficient and responsive maintenance service which supports the Governor’s efforts to embed a dignity and decency agenda? (See paragraph 3.2.5).
HMPPS
In Progress
Belmarsh (2020)
Will the prison take steps to improve the environment of the outpatients holding room (see section 6.2)?
Governor / Director
Winchester (2021)
More clinical space is needed on the wings, especially for confidential mental health consultations. When will this be facilitated? (See section 6.3).
Governor / Director
Winchester (2021)
What is the Minister’s plan to resolve the issue of permanent cell overcrowding and the fact that prison service instruction (PSI) 17/2012 states prisoners must be ‘able to use the wc with some privacy’ (see sections 3.2, 4.4, 5.1), which is impossible to achieve in HMP Winchester?
Ministry of Justice
In Progress
Wayland (2021)
The Board’s findings that almost 60% of survey respondents declared that they did not normally receive weekly bedding changes was disappointing, and a worse finding than previously found, when the response was evenly split. The Board draws the Governor’s attention to this finding and hopes that measures will be put in place to achieve a weekly bedding change as a …
Governor / Director
Wayland (2021)
The Board has been surprised to discover how few prisoners had had cell acceptance forms provided on their reception. Proper procedural implementation of this requirement would underline the prison’s acceptance of this practical demonstration of decency. The Board asks that an operational review be held into this identified failure in decency management (see section 5.1).
Governor / Director
Heathrow and City airports Short Term Holding Facilities (2021)
The Board repeats its recommendation that the Home Office should substantially improve the facilities for families and children in Terminal 5. These are currently excessively cramped and they lack integrated toilet, shower and baby-changing facilities.
Home Office
London Heathrow and City Airports (2022)
[London Heathrow Airport] The Board recommends that if a holding room is being reconstructed, consideration be given to accommodating men and women separately, as recommended by HM Inspectorate of Prisons. (See paragraphs 4.2.14 and 4.2.15)
Home Office
Hull (2022)
The Board would ask the minister to consider the issues of insufficient capacity within the prison estate which continues to see prisoners housed in double cells which are inadequate both in size and design for this purpose and impinge upon the right to privacy and dignity;
Ministry of Justice
Noted
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
The decor and general furnishing at Edinburgh airport HRs are in real need of redecoration. We understand that this work is being looked at for implementation. We are also waiting the installation of a flight monitor and the replacement of the old TV sets in the two holding rooms.
Other
Kent Coast Short Term Holding Facilities (STHF) (2023)
Try to make induction booths more private, so detained people, can feel at ease answering personal questions.
Other
Hull (2023)
Consider the issues of insufficient capacity within the prison estate which continues to see prisoners housed in double cells which are inadequate both in size and design for this purpose and impinge upon the right to privacy and dignity.
Ministry of Justice
Garth (2023)
For many years, complaints have been registered about the very inadequate waiting area in the healthcare unit. This needs to be addressed urgently.
HMPPS
Implemented
Cardiff (2023)
Whilst appreciating the fabric of the HMP Cardiff site plays a large part in this, what can be done to address prisoners having no access to out of cell space to eat food, which currently means in shared cells both men must eat with a shared toilet in the space?
HMPPS
Noted
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2024)
We reiterate our previous recommendation that the provision of safe and private facilities for women within Larne House RSTHF remains outstanding. The Home Office previously committed to undertake work to ensure that women were accommodated separately from men. The Board recommends work is urgently completed with the outcome that the safety and dignity of women in detention can be assured.
Other
Moorland (2024)
The repeated increases in operating capacity over the year without new buildings have necessitated the conversion of more single cells to accommodate two prisoners. The Board is concerned about the impact this is having on dignity and wellbeing. How does the Minister plan to reduce prison overcrowding?
Ministry of Justice
In Progress
Elmley (2024)
Substantial investment is required to bring existing accommodation up to an acceptable standard. Aspects, including access to clean, working showers and reliable heating are insufficient and provision continues to deteriorate.
Ministry of Justice
In Progress
Durham (2024)
Yet again, the Board has raised concerns about the levels of overcrowding and its impact on the dignity of prisoners. Yet again, we have received answers offering no hope of improvement. When will the Minister this issue actually resolve this issue?
Other
In Progress
Usk and Prescoed (2025)
The Board has concerns there are insufficient phones at HMP Prescoed and they lack privacy for the prisoners. What steps are you taking to resolve these issues and what is the expected timeframe for completion?
HMPPS
In Progress
Styal (2025)
How does the prison intend to provide more access to confidential spaces for discussions with prisoners on the wing?
Governor / Director
Health investigations(60)
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
RMOs and clinicians managing offender patients should afford such patients regular interviews in private.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
In respect of behaviour modification programmes and particularly in the absence of valid patient consent, a locally agreed procedure should be adopted in which the RMO should seek the advice of a suitably qualified person who is not a member of the clinical team responsible for the patient. This will …
east_of_england
Independent investigation: Tina Stevenson&2 babies, Hull (2005) — Rec 19.4
There should be production of information packs for service users and their relatives and carers concerning areas identified in the revised Mental Health Act Code of Practice and the Care Programme Approach. The documentation should reflect all rights and responsibilities afforded to them.
north_east_yorkshire
Independent investigation: Sindi Smith (SS), Stratford. London — Rec R26
Where possible the individuals should be told that information is being sought from/shared with other agencies. The reasons for this should also be explained.
london
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 4
The panel agreed that the term “Detain if wishes to leave” is not a satisfactory one. It is clearly open to interpretation. It is not in keeping with the processes required under the Mental Health (Northern Ireland) Order 1986 and could appear to mean detention by default. It could also …
northern_ireland
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Eleven
It is recommended that serious consideration is given by the Trust to develop and implement single sex inpatient services.
london
Independent investigation: Nurzida Galimozanova, Brixton (2000) — Rec 10.5
The inquiry panel recognises the potential issues relating to confidentiality raised in SlaM’s response. However, in practice staff should be encouraged to distinguish between withholding information or engagement from carers and friends where that is not justified and infringes the patient’s proper right to confidentiality, and those circumstances where engagement …
london
Independent investigation: Linda Goswell, Cygnet hospital, Bradford (2014) — Rec 5
Cygnet Health Care should ensure that all patients in their hospitals have the facility to lock their bedrooms and secure their belongings.
north_east_yorkshire
Joint Domestic Homicide Review and independent mental health homicide investigation … — Rec 14
Trust and Adult Social Care staff must consider how best to communicate information to Nearest Relatives, so they can be assured that the Nearest Relative clearly understands their role and rights under the Mental Health Act. Simplified versions of written materials are recommended, where they are not already in use.
north_west
Independent investigation: Antonio Tommaso, New Barnet (2014) — Rec 1
Although we recognise that the capital implications and future plans for the site must be taken into account, we recommend that, in conjunction with its commissioners the Trust takes urgent steps to ensure that all admission wards are gender specific or, at a minimum, to create gender-specific bedroom and functional …
london
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 7
The Trust Quality Committee should commission a specific project on the care, transportation and storage of the bodies of deceased patients to give wider assurance that the matters raised by Savile’s association with the hospital mortuary could not happen again (source: chapter six).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 6
Porters should receive training and support about the transportation and handling of deceased patients. De-briefing and counselling should be available for porters who are adversely affected by carrying out this duty (source: chapters six and nine).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
*Mental health homicide investigation legacy report into the care and … — Rec Recommendation Seven
The Trust will: o ensure that all relevant policies and procedures are reviewed, and amended where necessary, to ensure that all clinical staff are advised of the importance of copying in service users to all clinical letters and communications; o ensure that the Trust audits the compliance of this practice …
Mr X This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust
south_east
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 9
Legal clarification should be sought by the Trust (in conjunction with its multiagency partners) regarding patient rights in relation to confidentiality and reporting on to other statutory agencies. This guidance is of particular relevance to those women who fall ‘sub’ current MARAC, Vulnerable Adult and Safeguarding processes.
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 4
All service users who are considered for informal admission should: Have their capacity to consent to treatment assessed and recorded. Ensure that all assessments for women such as Ms X be conducted in private with no family or community members present. Ensure that If any aspect of …
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 14
The Trust must establish (with support from the Clinical Commissioning Groups) a revised interpreter service in order to ensure that no person subject to Forced Marriage or Honour-Based Abuse issues has to use a family member, a member of their local community, or anyone who could be seen to potentially …
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 13
Current advocacy services should be reviewed and steps taken to ensure that each service can provide specialists in Forced Marriage and Honour-Based Abuse. Steps should also be taken to ensure that these advocates are not drawn from local communities in order to maintain confidentiality and privacy. The Local Authority to …
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
Independent investigation into the care and treatment provided to Ms … — Rec Recommendation 12
Clear Trust guidance will be developed in relation to the confidentially and privacy needs of women like Ms X. Currently national guidance recommends that carers and families are always involved in full. New guidance needs to provide direction for health and social care professionals who have to navigate a complex …
Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust
south_east
Assurance Review: Trust recommendations — Rec 18
Consent • Consent for operations must be completed on every occasion. Any consent not completed correctly must be reported and investigated to improve practice. • Consenting practice should be subject to audit and should include whether the patient dated the consent and the practice of confirmation of consent where the …
north_west
An independent investigation into the care and treatment of mental … — Rec 1
The Trust must ensure that mechanisms are in place and used by staff to use preferred methods of communicating with patients, particularly when the preference is linked to a known disability.
Mersey Care NHS Foundation Trust
north_west
An independent investigation into the care and treatment of Adult … — Rec Recommendation 10
Application of the Mental Capacity Act (MCA) Adult 1 was taken to hospital under the MCA and remained in general hospital for an extended period of time (greater than 10 hours) without formal assessment under either the MCA or the MHA. The Trust and the Council must ensure that there …
south_west
Independent investigation into the care and treatment of Patient R: … — Rec 9
The Trust should revise their drug detection policy to include procedures around the use of drug detection dogs, and specifically a process for making service users aware that drug detection dogs may visit acute inpatient areas.
5 Boroughs Partnership NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Mr EF — Rec 1
Although we recognise that the capital implications and future plans for the site must be taken into account, we recommend that, in conjunction with its commissioners the Trust takes urgent steps to ensure that all admission wards are gender specific or, at a minimum, to create gender-specific bedroom and functional …
Mr EF who committed a homicide in May 2014. Mr EF was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
An independent investigation into the care and treatment of Patient … — Rec 5
Cygnet Health Care should ensure that all patients in their hospitals have the facility to lock their bedrooms and secure their belongings.
north_east_yorkshire
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must assure itself that all practices of seclusion and ‘de facto’ seclusion on the PICU, including where patients have been segregated from others after rapid tranquilisation, are fully compliant with the requirements of the Mental Health 1983 (amended 2007), the MHA Code of Practice and the MHA Reference …
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation: Alan Geddes, Aberdeen (2019) — Rec 5
HSCP/NHS A should design a protocol for when patients refuse consent to share information with relatives/carers; see the good practice guide, Carers & confidentiality (2018). This should include an indication of how frequently or in what circumstances this should be re-addressed and documented. It should also indicate the circumstances in …
scotland
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 8
The thorny issue of how to manage inter-team referrals where the service user is unaware of the referral needs to be properly debated within the context of good governance. It does not seem to be sufficient that the CRHT simply refuse to accept such referrals. Note The assistant directors of …
north_east_yorkshire
Independent investigation: Simran Sidhu (5)Aman Raj (23 mths), Southall Station … — Rec 3
All service users must be offered the opportunity to be interviewed on their own. When there are specific cultural or gender issues where this is not appropriate a chaperone should be considered. When there are known instances of abuse or coercion the service user must not be seen with the …
london
Independent investigation: Nurzida Galimozanova, Brixton (2000) — Rec 1
The panel recommends that when admissions and discharges are arranged: • the purpose of the admission is clarified through assessment and planned engagement in the hospital setting for the clinical team • the patient is informed of the purpose of their admission • the contribution of carers is recognised and …
london
Independent investigation: Nigel Yon, Neasden (2015) — Rec 7
Where there is a question of capacity to consent to treatment, CNWL must ensure there is a structured process used to assess and record capacity, with action plans as appropriate.
london
Independent investigation: Jordan Cooper, Washington (2011) — Rec 1
Where multiple health care providers are involved in the treatment and care of a patient, the discharging service should seek the permission of the patient to send discharge summaries to all involved agencies.
north_east_yorkshire
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R33
The trust should ensure that interpreters are used when necessary, especially where there may be language difficulties for a primary carer.
london
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 25
No deliveries should be allowed to the wards after 22.00 hours
london
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 23
When patients are allocated to the care of certain nurses, on each shift throughout the 24 hour period, the nurses should make specific time to engage with the patients in his/her charge. If there is a persistent problem from the patient’s side in achieving this, this should be reported as …
london
Independent Investigation into the care and treatment of X: October … — Rec 4
Where a decision is made to change a service user’s diagnosis, this should always be communicated in a face to face discussion with the individual, allowing time for explanation and any concerns and questions. We believe the Trust should ensure this is embedded into practice.
South Essex University Partnership NHS Foundation Trust
east_of_england
Independent Investigation into the care and treatment of X: October … — Rec 3
The Trust should review the policy for ensuring that service users are kept informed about their care, including copying correspondence to the service user.
South Essex University Partnership NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of Adult … — Rec Recommendation 2
MHA and NR rights Adult 2’s right to request that the local authority consider the patient’s case with a view to making an application for admission to hospital was dismissed or not given due consideration. The responses to her requests were not in line with the MHA and MHA Code …
south_west
An independent investigation into the care and treatment of Adult … — Rec Recommendation 1
Information given to relatives about the MHA and the Nearest Relative (NR) rights Adult 2 was not told her rights as the NR, specifically that she could formally request that the local authority consider the patient’s case with a view to making an application for admission to hospital. The Trust …
south_west
An independent investigation into the care and treatment of a … — Rec 3
The Trust to strengthen how it captures patient and family agreement with their care plans in the Electronic Patient Record, in line with its existing performance indicators on individuals and families receiving a copy of their care plan and people feeling involved in developing their care plans
south_east
An independent investigation into the care and treatment of a … — Rec 4
The Trust must ensure that patients are provided with appropriate information about medicines in order for them to be able to make an informed decision about consenting to accept the medicine. This is even more important when a medicine is prescribed off licence.
Mr P in Dorset NHS England has published an independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust
south_west
An independent inquiry into the care and treatment of Mr … — Rec R3
The trust should put steps in place to ensure that a discussion with the person using mental health services takes place to find out if they want their family, carers or friends to be involved in their care. Such discussions should take place at intervals to take account of any …
Mr S . At the time of the homicide (2011) Mr S was receiving care and treatment from Somerset Partnership NHS Foundation Trust
south_west
Independent investigation report into the care and treatment of Mr … — Rec 11
The Trust must assure itself and its commissioners that involve patients and their families (where appropriate) in decisions about transferring patients to other units.
midlands
A Learning Lessons Bulletin on the care and treatment of … — Rec 3
Interpretation services for patients should be easily accessible. The Commissioned Interpretation Services should be readily available to meet staff requirements in delivering a high quality service to patients and their families.
london
Independent investigation: Leanne Unsworth, Burnley (2019) — Rec 3
The Trust should ensure that all service users (and their families/carers) are fully involved in their care and treatment planning, including diagnostic discussions. Information should be provided in an accessible format and language.
north_west
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R28
The trust should ensure that CPA policies and procedures stress the importance of planning for and managing transitions. Advocacy services should be available for all patients when major changes are introduced to their care to ensure that they understand what is likely to happen.
london
Independent investigation: Ivy Torrie, Pocklington (2003) — Rec 17.5
There should be production of information packs for service users and their relatives and carers concerning areas identified in the revised Mental Health Act Code of Practice and the Care Programme Approach. The documentation should reflect all rights and responsibilities afforded to them and what to do in emergencies.
north_east_yorkshire
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003) — Rec 8.4.24
When dealing with a patient in the community, efforts should be made by mental health staff to conduct some sessions without other family members present, in order to gain a more accurate assessment.
wales
Independent investigation: Donald Lock, Findon (2015) — Rec 10
The Trust must ensure that proper consideration is given and information provided when suggesting medication to clients.
south_east
Independent investigation: Beata Slomiana, Finchley (2010) — Rec R2
The trust should use the facts of this investigation to run a multi-professional learning event to examine what ethical, professional and legal issues arise if a patient who is a suspect in a criminal case could incriminate himself or herself by answering staff questions.
london
Independent investigation into the care and treatment of Mr L — Rec 3
The Trust must assure itself that all practices of seclusion and ‘de facto’ seclusion on the PICU, including where patients have been segregated from others after rapid tranquilisation, are fully compliant with the requirements of the Mental Health 1983 (amended 2007), the MHA Code of Practice and the MHA Reference …
Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust
london
Partially Accepted
Scottish Fatal Accident Inquiries(2)
James Maughland
Hospitals (other than psychiatric hospitals) should review how they deal with the admission of patients with learning disability or mental illness and devise a protocol for identifying such patients and to ensure that there is proper communication with them not only on admission but throughout their stay in such hospitals. Where there is a patient in a general hospital who …
Mar 2003
Andrew Ritchie, Agnes Nicol and George Johnstone
It is essential that every doctor and nurse responsible for the care of a patient has access to all the records and all the documents and that full notes are available at all times. I can only hope that NHS Lanarkshire will ensure in future that, firstly there is full documentation recorded by both the doctors and nurses involved in …
Feb 2012
Article 2 learning points(2)
— LP 20
The prison must ensure that when a prisoner is on a bed watch in hospital and in a poor state of health, following an incident of life threatening self-harm, they achieve a balanced risk assessment of the need to have prison officers present to protect the public and the prisoner’s …
HMP Altcourse
Accepted
— LP 9
Independent Monitoring Boards across NOMS may wish to consider the merits or otherwise of visiting prisoners whilst they are temporarily resident in external settings such as hospitals. This could be particularly relevant if a prisoner is absent from the prison for a protracted period of time.
Independent Monitoring Boards
Rejected
Detention investigations(18)
Assessment of government progress in implementing the report on the … — Rec 21
Waiting environments for medication distribution should be reviewed to ensure privacy and dignity, and support personal safety.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R30
Pregnant residents should be allowed to eat their meals away from the main dining rooms without having to obtain permission from healthcare staff.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 7
No immigration detention facility should be built in future with a barely screened toilet inside a shared room, and this set-up should be upgraded in all existing facilities.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 32
Group 4 (and other contractors) provides the cheapest phone service possible to detainees and that it ensures its phone systems fully meet the needs of detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 31
the food be checked daily for quality and quantity by the contract monitor.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 36
I recommend that the Immigration Service considers introducing music or radio into vans and that detainees be offered something to read or do during the wait.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 11
I recommend that staff are instructed not to touch detainees or their beds while waking them up.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 3
I recommend that washing, eating and toilet facilities be made available at all sites where detainees are likely to be held for more than an hour.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R26
G4S managers and the SMT should: • improve the environment in the reception area at Brook House and make it more welcoming; • consider how all new arrivals can be interviewed in privacy; and • agree with the Home Office how they will provide showers for new arrivals. (To be …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 32
I recommend that staff be trained to ask the detainee by what name he/she would like to be called and to check with him/her their pronunciation of the name.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R20
Serco should consider how residents might be given greater opportunities to cater for themselves, including by expanding the cultural kitchen facilities, the choice of foods in the shop and providing facilities for residents to store and cook food and make snacks for themselves.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R16
Managers should continue to look for opportunities to improve the physical environment at Yarl’s Wood and make it less prison-like. In particular they should discuss with the Home office whether they can give residents access to more open space and whether they can increase natural light in the corridors and …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R13
Managers should review policy and procedure in relation to entering residents’ rooms and interviews with and checks on residents, particularly at night, to ensure that interviews and checks are as thorough as necessary and carried out in a consistently by all staff.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 66
a single lock-down time be introduced across the detention estate, but that detainees be allowed to smoke in their rooms and that a television is provided in each room or dormitory.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 65
courtesy keys and locks be introduced in removal centres.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 9
I recommend that IND considers what information might usefully be given to detainees about Use of Force and in what form. Care must be taken to avoid suggestions of oppression or intimidation.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 6
I recommend that the Immigration Service urgently considers the provision of pagers to detainees at Oakington.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 56
I recommend that the creation of care suites across the IRC estate should be taken forward as a priority.
Immigration Detention
Independent reviews(34)
Shaw Detention Review — Rec 46
Recommendation 46: I recommend that the Home Office review the use of fellow detainees as interpreters for induction interviews.
Immigration
Shaw Detention Review — Rec 36
Recommendation 36: I recommend that Home Office Detention Operations carry out an audit of reception and holding environments to ensure that the policy on searching out of sight of other people is properly followed.
Immigration
Shaw Detention Review — Rec 35
Recommendation 35: I recommend that the service provider at Yarl's Wood should only conduct searches of women and of women's rooms in the presence of men in the most extreme and pressing circumstances, and that there should be monitoring and reporting of these cases.
Immigration
Morecambe Bay Investigation — Rec 17
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, an improved ability to observe and respond to all women …
Health & Social Care
Wessely Review — Rec 101
Safeguards should be created so that patients are able to continue religious or spiritual practices while detained in hospital. These should prevent the use of restrictive practices that limit a person's access to religious observance.
Health & Social Care
Accepted
Wessely Review — Rec 91
The definition of single sex accommodation should be tightened up to ensure a genuinely single sex environment with separate access to any shared daytime space.
Health & Social Care
Accepted
Wessely Review — Rec 90
All existing dormitory accommodation should be updated without delay to allow patients the privacy of their own room.
Health & Social Care
Accepted
Wessely Review — Rec 80
The Government and the CQC should consider developing a new independent 'Hospital Visitors' role, the main purpose of which is to monitor day-to-day life in the hospital and ensure that patients are treated with dignity and respect.
Health & Social Care
Accepted
Wessely Review — Rec 70
Providers should take urgent action to end unjustified use of 'blanket' restrictions applied to all patients.
Health & Social Care
Accepted
Wessely Review — Rec 69
Wards should not use coercive behavioural systems and restrictions to achieve behavioural compliance from patients, but should develop, implement and monitor alternatives.
Health & Social Care
Accepted
Wessely Review — Rec 11
The Government should consult upon: a. whether the MHA should provide that a person can consent in advance to confinement for medical treatment for mental disorder, or to empower an attorney or court appointed deputy to give consent on their behalf; and b. what safeguards would be required.
Health & Social Care
Accepted
Darzi Review — Rec 19
Patient engagement. The patient voice is not loud enough. The NHS should aspire to deliver high quality care for all, all of the time. That not only means care that is safe and effective but that treats people with dignity, compassion and respect, making their experiences as positive as they …
Health & Social Care
Jones: Patronising Disposition Review — Rec 20
Families told me that they felt that the way in which death certificates were issued following the fresh inquests – with no covering letter and in some cases unexpectedly – caused great pain and distress. I accept the assurance provided to me by the Home Office's that death certificates are …
Policing & Security
Jones: Patronising Disposition Review — Rec 18
I would encourage the Chief Coroner to ensure that all coroners are made aware of the experience of the Hillsborough families as set out in this report. Coroners should ensure that the decisions they make on toxicology – especially in respect of children – are made in a sensitive way, …
Policing & Security
Jones: Patronising Disposition Review — Rec 9iv
The use of pen portraits at the fresh Hillsborough inquests helped to put the families at the heart of proceedings. The process was vital in humanising the inquests and was both important and therapeutic for the bereaved families. In my view, the use of pen portraits is an important point …
Policing & Security
Jones: Patronising Disposition Review — Rec 7
Bereaved families told me that they felt degraded by much of the press coverage of the Hillsborough disaster, as well as harassed by individual journalists and press photographers. Both of these aspects of the media's behaviour undoubtedly caused great distress. Both the Independent Press Standards Organisation (IPSO) and the Independent …
Policing & Security
Jones: Patronising Disposition Review — Rec 5
It has been submitted to me that the issue of family members being told that their loved one is the 'property of the coroner' and being prevented from seeing, touching and holding their body in part arises from a lack of clarity in law as to the rights of bereaved …
Policing & Security
Jones: Patronising Disposition Review — Rec 3
The Hillsborough families' experience demonstrates the need for the bereaved family and friends of those who have died to be questioned only as absolutely necessary in the immediate aftermath of a major incident. Minors should not be questioned in the absence of family or an appropriate adult. In presenting this …
Policing & Security
Harris Review: Deaths in Custody — Rec 81
Should such consent not be given, the person in custody should have an informed discussion periodically with healthcare professionals to revisit the decision made.
Justice & Legal
Wessely Review — Rec 84
The physical environment of wards needs to be improved, through co-design and co-production with people of relevant lived experience, to maximise homeliness and therapeutic benefit and minimise institutionalisation.
Health & Social Care
Accepted
Wessely Review — Rec 15
Patients should have greater rights to choose to disclose confidential information to additional trusted friends and relatives, including through the NP nomination process or advance choice documents.
Health & Social Care
Accepted
Wessely Review — Rec 14
A new Interim Nominated Person (INP) selection mechanism should be created for those who have not nominated anyone and do not have capacity to do so.
Health & Social Care
Accepted
Wessely Review — Rec 13
Patients should be able to choose a new Nominated Person (NP) to replace the current Nearest Relative (NR) role under section 26 of the MHA.
Health & Social Care
Accepted
Wessely Review — Rec 9
Patients should be able to appeal treatment decisions at the Mental Health Tribunal following a SOAD review.
Health & Social Care
Accepted
Wessely Review — Rec 8
Patients should be able to request a SOAD review from once their care and treatment plan has been finalised or 14 days after their admission, whichever is the sooner; and again, following any significant changes to treatment.
Health & Social Care
Accepted
Keogh Cosmetic Interventions Review — Rec 27
The RCS Interspecialty Committee on Cosmetic Surgery should develop and describe a multi-stage consent process for operations. This consent process should be undertaken by the operating surgeon and its use should be mandated as part of the Code of Practice.
Health & Social Care
Wanless Review — Rec 15
A more effective partnership between health professionals and the public should be facilitated, for example, by: the setting of standards for the service to help give people a clearer understanding of what the health service will, and will not, provide for them; development of improved health information to help people …
Health & Social Care
Paterson Inquiry — Rec 4
We recommend that there should be a short period introduced into the process of patients giving consent for surgical procedures, to allow them time to reflect on their diagnosis and treatment options. We recommend that the GMC monitors this as part of 'Good Medical Practice'.
Health & Social Care
Paterson Inquiry — Rec 3
We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised, is explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by …
Health & Social Care
Taylor Youth Justice Review — Rec 15
In order that the particular needs of girls are met while they are in police custody, any girl aged under 18 who is arrested should be allocated a named female officer who is responsible for her welfare. (Paragraph 71)
Justice & Legal
Wessely Review — Rec 82
The CQC should develop new criteria for monitoring the social environments of wards. These criteria should be the yardstick against which wards are registered and inspected and this should be reflected in ratings and enforcement decisions.
Health & Social Care
Accepted
Wessely Review — Rec 7
Decisions about medication should, wherever possible, be in line with the patient's choice and patients should have a right to challenge treatments that do not reflect that choice.
Health & Social Care
Accepted
Angiolini Review — Rec 93
Police training should address the particular stressors that affect women detainees and young women in particular. Officers should understand the additional impact of these stressors upon women with mental health difficulties and the importance of access to healthcare.
Policing & Security
Accepted
Ockenden Review — Rec 13
Bereavement care. Essential action: Trusts must ensure that women who have suffered pregnancy loss have appropriate bereavement care services. • Trusts must provide bereavement care services for women and families who suffer pregnancy loss. This must be available daily, not just Monday to Friday. • All trusts must ensure adequate …
Health & Social Care
Accepted
PHSO casework decisions(147)
P-002266 — West Midlands Ambulance Service University NHS Foundation Trust
Ms U complained paramedics brought a television documentary crew to her home while her mother was critically ill and needed urgent help, causing her significant distress.
NHS in England
Oct 2023
P-002938 — University Hospitals of Derby and Burton NHS Foundation …
Mrs A complained the Trust issued a DNAR order without family consent, administered incorrect opioid pain relief leading to her husband's death, and failed to explain his care plan.
NHS in England
Sep 2024
P-003610 — Norfolk and Suffolk NHS Foundation Trust
Ms A complained the Trust breached her privacy and dignity by showing CCTV footage in March 2024, despite earlier assurances. This caused her distress and harm.
NHS in England
Jun 2025
P-004511 — North Tees and Hartlepool NHS Foundation Trust
Miss L complained a doctor performed an internal examination without explanation or consent after childbirth, causing her significant pain, distress, and a lasting feeling of violation.
NHS in England
Partly Upheld
Dec 2025
P-001121 — East Suffolk and North Essex NHS Foundation Trust
Mrs L complained staff refused her entry as a familial carer to the ED and ward, were rude, and frequently woke her for observations, causing distress to her and her daughter.
NHS in England
Sep 2021
P-001396 — Royal Free London NHS Foundation Trust
Mrs U complained the Trust refused to provide mittens for her mother, causing her to remove her oxygen mask and die.
NHS in England
May 2022
P-001386 — Milton Keynes University NHS Foundation Trust
Mrs A complained a Do Not Attempt CPR (DNACPR) order was added without consent, and an unsecured commode led to a fall.
NHS in England
May 2022
P-001585 — A dental practice in the Stockton-on-Tees area
Ms O complained her dental appointment was cancelled after she was asked about her COVID-19 vaccination status, leading to a three-month delay in denture repair and agony.
NHS in England
Aug 2022
P-001974 — A care home in the Northamptonshire area
Mrs A and Mrs K complained the care home sent Mr B to hospital against his will and the Trust unnecessarily admitted him, failed to manage medication/oral care, and caused his deterioration.
NHS in England
Sep 2022
P-001694 — HCRG Care Group
Mrs O complained about unprofessional conduct and mistreatment of Mr A by a carer, including refusal to change an incontinence pad, and HCRG's failure to provide a male carer and dismiss family concerns.
NHS in England
Nov 2022
P-002302 — Sherwood Forest Hospitals NHS Foundation Trust
Trust staff allegedly took Ms P's baby without permission, misdiagnosed her conditions, and fed her baby yoghurt without checking for allergies.
NHS in England
Nov 2023
P-002365 — King's College Hospital NHS Foundation Trust
Mrs D complained a DNACPR notice was placed on her father's records without consent, his resuscitation wishes were ignored, and the Trust failed to escalate her complaint.
NHS in England
Dec 2023
P-002523 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs U complained her hair was shaved during cyst removal against her wishes and only some cysts were removed, causing distress, and that the Trust's complaint investigation was biased.
NHS in England
Mar 2024
P-002646 — Manchester University NHS Foundation Trust
Mrs G complained the Trust failed to notify her of her father's death, gave his property to someone else, and prevented her from seeing him on the ward.
NHS in England
Upheld
May 2024
P-002760 — Royal Devon University Healthcare NHS Foundation Trust
Mr R complained about his father's care, including being left shoeless, unclean sheets, cold food, an open window, staff comments about his mother, and poor communication of his death.
NHS in England
Jul 2024
P-002752 — A practice in the City of Derby area
Mrs R alleged the midwife failed to signpost housing support, and the Trust did not help with a birth plan, communicate during labour, get consent, or address her anxiety after a traumatic birth.
NHS in England
Partly Upheld
Jul 2024
P-003285 — Warrington and Halton Hospitals NHS Foundation Trust
Miss E complained staff performed foetal scalp monitoring, additional blood samples, and an episiotomy during her labour without her consent, causing lasting psychological and physical trauma.
NHS in England
Upheld
Jul 2024
P-002952 — Mid Yorkshire Teaching NHS Trust
Mrs A complained the Trust discharged her husband with uncontrolled diabetes, discussed a DNACPR without proper communication, and misinformed him about his condition.
NHS in England
Sep 2024
P-002922 — United Lincolnshire Hospitals NHS Trust
Mrs G complained the Trust poorly managed her husband's diabetes medication, delayed a diabetic nurse visit, wrongly placed him on end-of-life care, and failed to consider their wishes regarding a DNACPR.
NHS in England
Upheld
Sep 2024
P-002945 — Manchester University NHS Foundation Trust
Miss U complained about inappropriate restraint, an unwarned injection, excessive force by security, an invalid sectioning, an inaccurate diagnosis, and not being informed of a needlestick injury or sectioning.
NHS in England
Sep 2024
P-002980 — Sandwell and West Birmingham Hospitals NHS Trust
Mr K complained his mother caught COVID-19 and died after being moved from a side room to a shared ward in December 2022.
NHS in England
Sep 2024
P-002926 — University Hospitals Birmingham NHS Foundation Trust
Miss I complained her father's condition deteriorated from able-bodied to disabled, leading to his death, and that the family was pressured into a DNR order and denied visits.
NHS in England
Sep 2024
P-002987 — University Hospitals Coventry and Warwickshire NHS Trust
Mrs A complained her husband was improperly moved from A&E, left unattended during an active rectal bleed, not offered active treatment, and discussed a DNACPR order without family support.
NHS in England
Partly Upheld
Sep 2024
P-003362 — Northern Lincolnshire and Goole NHS Foundation Trust
Miss S complained the Trust failed to disclose her mother's diagnosis and adequately meet her nutrition and hydration needs, causing distress and concern about hastened deterioration. She also cited poor end-of-life care planning and communication.
NHS in England
Upheld
Feb 2025
P-003523 — Taunton and Somerset NHS Foundation Trust
Mrs A complained her late husband was inappropriately catheterised without consent or assessment for urinary retention or mental capacity, alleging inappropriate restraint was used.
NHS in England
Apr 2025
P-003700 — Sussex Partnership NHS Foundation Trust
Ms F complained Dr A discussed her daughter E's needs with another service without consent, lied about disclosures, and about missing records and poor complaint handling.
NHS in England
Jul 2025
P-004430 — Dartford and Gravesham NHS Trust
A daughter complained her father received inadequate nutrition and fluids, delayed feeding tube insertion, poor supervision, and insufficient toileting assistance across multiple wards.
NHS in England
Dec 2025
P-004473 — University Hospitals Birmingham NHS Foundation Trust
Mrs U complained her sister, Ms A, experienced delayed pain relief, untimely personal care, and inadequate prevention/treatment of C. difficile, which contributed to her death.
NHS in England
Upheld
Dec 2025
P-001067 — Essex Partnership University NHS Foundation Trust
Mr and Mrs A complained about inadequate communication before Mrs A's discharge from a mental health hospital, her premature discharge, and a lack of dignity and appropriate care during a subsequent seclusion. They also cited poor complaint handling.
NHS in England
Partly Upheld
Apr 2021
P-001112 — University College London Hospitals NHS Foundation Trust
Mr L complained about an inadequate biopsy, two breaches of confidentiality regarding his HIV status, premature hospital discharge, and poor handling of his complaint.
NHS in England
Upheld
Sep 2021
P-001137 — Mid and South Essex NHS Foundation Trust
Mrs W complained about her late husband's poor nursing care, inadequate communication, lack of mental support, and the Trust disposing of his belongings.
NHS in England
Upheld
Oct 2021
P-001233 — Buckinghamshire Healthcare NHS Trust
Ms T complained the Trust provided inadequate care for her partner Mr S, including poor hydration, hygiene, and compassion, and failed to communicate his deteriorating health and death.
NHS in England
Upheld
Dec 2021
P-001238 — Cambridge University Hospitals NHS Foundation Trust
Ms U complained the Trust failed to provide compassionate care, advice, and follow-up after her miscarriage, and then mishandled her subsequent complaint.
NHS in England
Upheld
Dec 2021
P-001272 — Manchester University NHS Foundation Trust
Mrs E complained the Trust failed to involve her in her mother's care, provide adequate personal/palliative care, timely diagnose a kidney infection, and maintain hygiene, leading to sepsis via a Hickman line.
NHS in England
Partly Upheld
Jan 2022
P-001531 — A dental practice in the Bedfordshire area
Mr A complained a dentist attempted tooth removal in May 2021 without adequate pain relief, ignoring his pain, causing ongoing discomfort.
NHS in England
Sep 2022
P-001543 — Mersey Care NHS Foundation Trust
Ms O complained a community mental health nurse breached her and her father's confidentiality by sharing a confidential opinion.
NHS in England
Sep 2022
P-001534 — Gateshead Health NHS Foundation Trust
Mrs I complained staff made insensitive comments and performed unnecessary observation checks on her mother while she was approaching end-of-life care, causing distress.
NHS in England
Sep 2022
P-001570 — Mid and South Essex NHS Foundation Trust
Ms C complained the Trust failed to closely monitor Mr C, who was agitated, leading to his death. She also cited conflicting statements from staff about his end-of-life care.
NHS in England
Oct 2022
P-004561 — Milton Keynes University Hospital NHS Foundation Trust
Mrs Y alleged staff at Milton Keynes University Hospital failed to provide timely pain relief and fluids, neglected hygiene, poorly managed post-surgical pain, and did not prevent falls for her mother.
NHS in England
Partly Upheld
Jan 2026
P-001722 — Leeds Teaching Hospitals NHS Trust
Miss I complained Trust staff used excessive force and neglected her late partner, Mr E, between August and September 2021, resulting in physical bruising.
NHS in England
Jan 2023
P-001764 — Northampton General Hospital NHS Trust
Ms A complained Northampton General Hospital NHS Trust failed to supervise her father in the toilet, implemented a DNACPR order without her consent, and miscommunicated his death.
NHS in England
Jan 2023
P-001741 — Portsmouth Hospitals NHS Trust
Mrs C complained about inadequate care in the ED during her pregnancy, leading to her experiencing a miscarriage in a toilet after waiting hours without being seen, causing severe trauma and distress.
NHS in England
Partly Upheld
Jan 2023
P-001812 — A care home in the Sunderland area
Mrs R complained care home staff left her late father, Mr N, in urine and excrement despite paid pads, leading to skin lesions, pain, and loss of dignity.
NHS in England
Feb 2023
P-001981 — West Hertfordshire Hospitals NHS Trust
Mrs U complained her husband contracted COVID-19 at the Trust, leading to a heart attack and death. She also alleged poor hygiene care, resulting in thrush and no appropriate discharge medication.
NHS in England
May 2023
P-002031 — North East Ambulance Service NHS Foundation Trust
Paramedics moved her husband to an ambulance undignifiedly and unsafely, causing distress and potentially impacting his later hospital admission and death.
NHS in England
Jun 2023
P-002259 — South Tees Hospitals NHS Foundation Trust
Mrs R complained she suffered permanent nerve damage due to inadequate turning during a ten-day induced coma. She also felt ignored by the Trust regarding her ongoing symptoms.
NHS in England
Oct 2023
P-002262 — Chesterfield Royal Hospital NHS Foundation Trust
A daughter complained that staff allowed her mother to die traumatically and painfully, failing to follow the care plan, reapply a CPAP mask, or give morphine promptly.
NHS in England
Oct 2023
P-002256 — University Hospitals Birmingham NHS Foundation Trust
A son complained his dying father was publicly informed of his condition, discharged without support, lacked appropriate home assessment and transport, and received no bereavement counselling.
NHS in England
Oct 2023
P-002306 — The Dudley Group NHS Foundation Trust
Mrs D complained her mother developed fatal pressure sores due to neglect, citing poor communication and frequent ward changes as contributing factors to her deteriorating health.
NHS in England
Nov 2023
P-002466 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complained her grandmother received poor hygiene care, was discharged without a care package or oxygen instructions, and capacity for a DNAR form was questionable.
NHS in England
Upheld
Feb 2024
LGO / SPSO decisions(268)
201104151 — Ayrshire and Arran NHS Board
When Mr C's mother died in hospital, he made arrangements with a funeral home to have her body collected and prepared for cremation. Mr C complained that his mother's body was not released by the hospital until late afternoon two days later. He was particularly upset because he had been …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102748 — Orkney NHS Board
Mrs C received care and treatment from her GP (in a practice administered by the board) in relation to pneumonia, bunion pain and multiple sclerosis. In 2006, Mrs C phoned her GP in the early morning, complaining of being unwell. The GP visited her at home and referred her to …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2012
201102321 — Greater Glasgow and Clyde NHS Board
Mr C complained on behalf of his partner (Ms A) who was a hospital in-patient receiving treatment for schizoaffective disorder (a mental disorder affecting thinking processes and mood). Ms A was prescribed unilateral electroconvulsive therapy (ECT – a treatment that involves sending an electric current through the brain). This was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2012
201102277 — Forth Valley NHS Board
Mr C made several complaints about the care and treatment he received in hospital, most of which we did not uphold. He said that a communication failure meant that staff were not expecting him when he arrived. However, we found that the staff nurse had been told that he was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2012
201200240 — A Medical Practice in the Ayrshire and Arran …
Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2012
201204783 — A Housing Association
Mr Cs son (Mr A) had died, leaving a widow and young family. Mr A and his widow were tenants of the housing association. After Mr A died, Mr C handled matters, including contacting the association within days of his son's death. Mr C complained that the rental direct debit …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Jul 2013
201203403 — A Medical Practice in the Greater Glasgow and …
Ms A was removed from the practice's treatment list. She believed this was inappropriate, and complained to the practice. She remained dissatisfied when she received their response and her partner (Mr C) complained to us on her behalf. When we investigated, we found that the practice had not met the …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2013
201103691 — Ayrshire and Arran NHS Board
Mrs C's late mother (Mrs A) was admitted to hospital following a stroke. She was transferred to another ward a few days later. The day after her transfer to the ward, Mrs C told a nurse that her mother had a headache and needed pain relief. Mrs C said that …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2013
201204853 — A Medical Practice in the Forth Valley NHS …
Mr C complained that his medical practice refused to update him on changes in his son (Master A)s medical file, about which his estranged wife had not told him. Mr C also complained that the practice had prevented him from transferring his son to an alternative practice in the area. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013
201204558 — Grampian NHS Board
Miss C's sister (Miss A) fell at home and was admitted to a hospital. Although she injured her back in the fall, her health had already been deteriorating for around two months. Miss A had a history of alcoholism and was underweight, and her GP had been treating her for …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2013
201204522 — Glasgow Housing Association Ltd
Mr C needed a lot of support with housing matters. He was asked to go to his local housing office about a rent matter and called in, expecting to see one of two officers he had dealt with before, but they had both retired. He was introduced to his new …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2013
201203006 — Orkney NHS Board
Miss C's sister (Miss A) was admitted to hospital after a fall at home. Miss A had injured her back in the fall, but her GP noted in his referral letter that her health had been declining for some time. She had a history of alcoholism, a number of medical …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2013
201300409 — Ayrshire and Arran NHS Board
Ms C complained about her care and treatment during the birth of her son. In particular, she was concerned about the attitude of the midwife - she said that the midwife had snapped at her, had not listened to her and had not explained what was happening. She was concerned …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2014
201401305 — A Dentist in the Lothian NHS Board area
Mrs C complained that part of her dental work was provided on a private basis without her prior knowledge or consent. She said that she was not given a written treatment plan or cost comparison before the treatment was carried out. The dentist said that Mrs C was given a …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2015
201601930 — Lothian NHS Board - Acute Division
Mr C complained that the board failed to provide the results of a scan that he underwent at the Western General Hospital. He said that his GP had not been given the results of the scan, and that when he called the board he was given results over the phone …
SPSO (Scottish Public Se…
Health
Upheld
Jan 2017
201703864 — Grampian NHS Board
Mr C made a number of complaints about an inginual hernia repair (an operation to repair a weakness in the abdominal wall) he underwent at Dr Gray's Hospital. Mr C required to have further surgery a week later to remove a testicle due to a rare but recognised complication of …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2018
201703685 — Lothian NHS Board - Acute Division
Mrs C had knee replacement surgery at the Royal Infirmary of Edinburgh. She also underwent manipulation under anaesthetic (MUA - a procedure to try and improve movement) to try and relieve knee stiffness after the operation. Mrs C complained about the board's communication with her following the knee replacement surgery. …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2018
202500059 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2026
202304648 — Dumfries and Galloway NHS Board
C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into …
SPSO (Scottish Public Se…
Health
Not Upheld
Feb 2026
21-002-476c — Bupa Care Homes (AKW) Limited (21 002 476c)
Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-002-476b — Ardenlea Grove Care Home (21 002 476b)
Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-002-476a — University Hospital Birmingham NHS Foundation Trust (21 002 …
Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …
LGO (Local Government & …
Health
Not Upheld
Jul 2022
21-002-476 — Solihull Metropolitan Borough Council
Summary: We found staff from the Nursing Home failed to take Mrs U to the toilet when she asked. The Nursing Home also did not keep full and accurate records. By not taking Mrs U to the toilet when she asked staff were not adhering to her care plan and …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
201005089 — Lothian NHS Board
Ms C was awaiting reconstructive surgery after treatment for breast cancer. She told us that when she was seen in an out-patients clinic in February 2010 she was led to believe that the waiting time for surgery was about six months. She later found out that the waiting time was …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2011
201004596 — Lanarkshire NHS Board
Mrs C was admitted to a hospital in which her husband was already a patient. She complained that a member of hospital staff wrote in her medical records that her husband was dying, and that a nurse told her daughter this. The Board apologised and took action to stop this …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2011
201005373 — Grampian NHS Board
Mr C complained that an employee of Grampian NHS Board passed on negative remarks about him (made by a third party) to his sister-in-law. This was in relation to the search for a care home for their relative, Mr A. The investigation revealed that the information had been relevant to …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2011
201005315 — Highland NHS Board
Mrs C complained about the care provided to her by nursing staff during her stay at Raigmore Hospital. In particular she was concerned about the attitude of nursing staff and and about delays in attending to her needs. We did not find sufficient evidence to support her claims that the …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2011
201100271 — Ayrshire and Arran NHS Board
Mr C complained about care and treatment provided to his wife, Mrs C. Mrs C was admittted to Accident and Emergency at Ayr Hospital in December 2010 after a fall at her home. She had a suspected fracture. After being assessed, it was confirmed that she had a fractured pelvis. …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2011
201100261 — A Medical Practice, Highland NHS Board
Ms C complained about the care and treatment she received after she registered with a new medical practice. She said that a GP did not carry out a general check of her health and that the action taken by the practice in relation to her symptoms of depression was inconsistent. …
SPSO (Scottish Public Se…
Health
Not Upheld
Oct 2011
201103646 — Tayside NHS Board
Mr C's wife (Mrs C) was admitted as an emergency case to hospital, but passed away the next day. Mr C was unhappy that the board did not contact him to tell him that his wife had died, and that he only found this out when he called to ask …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2012
201200021 — A Medical Practice in the Tayside NHS Board …
Ms C complained that her medical practice had kept information from her about her hospital test results. She also said that when she wrote a formal letter of complaint to the practice they had failed to address the issues she raised. Our investigation found, however, that the practice had correctly …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2012
201200239 — A Medical Practice in the Ayrshire and Arran …
Ms A requested that her first appointment with a new medical practice be longer than usual. Ms A was late for the appointment, and when the GP refused to see her she became upset. She wrote a letter about the situation while she was in the practice but this was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201102610 — Lothian NHS Board
Mrs C complained about the care and treatment her father (Mr A) received while in hospital. Mrs C said that her family were asked to contact the ward on the day of Mr A's operation. She said that when they did this, they were made to feel over-anxious. Mrs C …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201200144 — A Medical Practice in the Fife NHS Board …
Mrs C complained that her mother (Mrs A) had mobility problems, which caused her great difficulty in attending the medical practice. Mrs C wanted an assurance that the GPs would make non-emergency home visits to Mrs A if required. The practice explained that there would have to be a clinical …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2013
201203440 — A Medical Practice in the Lothian NHS Board …
Mr C complained about various aspects of his treatment by reception staff and the practice manager when he attended the practice on two occasions. Our investigation found that there had been shortcomings in a number of areas and because of this we upheld the complaint. However, we also noted that …
SPSO (Scottish Public Se…
Health
Upheld
Apr 2013
201101313 — Greater Glasgow and Clyde NHS Board - Acute …
Ms C complained about the care and treatment that her late father (Mr A) received in hospital before his death. She said that staff failed to recognise and manage her father's pain and to act on her concerns about this. During our investigation, we took independent advice from one of …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2013
201203679 — A Medical Practice in the Highland NHS Board …
Mrs C was unhappy with care and treatment she had received from a doctor at the medical practice, and had tried to avoid consulting him. However, she had to see him for a medication review. She was unhappy about this and raised concerns about the treatment she received from him …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2013
201204747 — Forth Valley NHS Board
Mr C, who is a MSP, complained on behalf of Mrs A's family. Mrs A, who was 94, was admitted to hospital with shortness of breath, and chest and back pain. Her family were told that she would be examined for a possible chest infection or a clot on her …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2013
201204951 — An NHS Board
Mr C was being treated for HIV (Human immunodeficiency virus - the virus that causes acquired immunodeficiency syndrome (AIDS)). He was unhappy because the board sent his medication to a family member's home, rather than to his medical practice as requested. A family member opened the package and became aware …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2013
201302758 — A Medical Practice in the Forth Valley NHS …
Mrs C complained about a specific consultation with a GP in her local practice. She attended with a flare-up of her longstanding physical health problems, which included fibromyalgia and osteoarthritis (conditions that cause the muscles and joints to become painful and stiff). She complained that the GP was dismissive of …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201302723 — A Medical Practice in the Grampian NHS Board …
Mr C complained about the care and treatment provided to his father (Mr A) by the medical practice after he raised concerns about Mr A's deteriorating health. Specifically, he was concerned that doctors failed to assess his father's deteriorating mental health. Mr A refused to go into respite care, was …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201302512 — Lothian NHS Board
Mr C and his mother (Mrs A) received a visit from two community psychiatric nurses (CPNs) who assessed his and his mother's needs. At the end of the interview they mentioned that the results might be shared with colleagues in the social work department. Mr C was at that time …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201204540 — Lothian NHS Board
Ms C's late mother (Mrs A) was treated in hospital as an in-patient for illnesses that included pneumonia and chronic heart failure. Ms C complained that during that time the hospital communicated inadequately with her and other family members about Mrs A's medical condition. In particular Ms C said that …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
201302499 — Lothian NHS Board
Mr C, who is a prisoner, complained about the late supply of medication by the health centre based within the prison. He was also unhappy with the way in which his complaint was handled, saying that he had difficulties obtaining a complaints form and that health centre staff had opened …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2014
201204572 — Lothian NHS Board
Mrs C's 85-year-old father (Mr A) suffered from dementia, and had a history of heart problems and abdominal cancer. Mrs C complained that he was twice discharged from the Royal Infirmary of Edinburgh when he was not fit for discharge. She also complained about a lack of communication within the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2014
201306193 — Borders NHS Board
Mrs C told us that her late mother (Mrs A) did not get the care she deserved during the last few hours of her life at Borders General Hospital. She said that at other times the standard of care provided during her mother's stay in hospital had been good or …
SPSO (Scottish Public Se…
Health
Upheld
Sep 2014
201405741 — Lanarkshire NHS Board
Mr C complained that his prison health centre revealed information about his health to Scottish Prison Service (SPS) staff. Mr C also complained about the board's response to his complaint. We looked at the board's investigation, and at an SPS investigation that was carried out in partnership with the board. …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2015
201404431 — Fife NHS Board
Mrs C complained about the poor communication by Victoria Hospital in relation to her father (Mr A), who had been receiving dialysis treatment (a form of treatment that replicates many of the kidney's functions). Following a discussion with Mr A's family, the medical team at the hospital decided to stop …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2015
201305515 — West Lothian Council
Miss C, a council tenant, complained about various aspects of the services she had received from the council. She complained that a warning marker had been put on her records, and had not been reviewed in line with policy. This marker indicated that staff should visit her in pairs. The …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Jul 2015
201404470 — Highland NHS Board
Ms C, an advocacy worker, complained about Mr A's care and treatment at Caithness General Hospital, where he underwent keyhole surgery to remove his gallbladder. She noted that Mr A was led to believe the surgery would be routine, but complications were encountered, requiring corrective surgery at Raigmore Hospital and …
SPSO (Scottish Public Se…
Health
Partly Upheld
Aug 2015
Domestic Homicide Reviews(52)— showing 50 strongest matches
Chiltern — recommendation Panel Recommendation
Review Chaperoning Policy to ensure that all domestic abuse victims, regardless of gender, have an opportunity to have a private consultation.
Buckinghamshire Healthcare Trust | Frimley Health …
Buckinghamshire Healthcare NHS Trust
Sheffield — recommendation 4.1.2.1
When using interpreters to ask women for sensitive personal information such as in “routine enquiry” the gender of the interpreter must be considered. A male interpreter could have an impact on the response.
Sheffield Teaching Hospitals NHS Foundation Trust
Sheffield Teaching Hospitals NHS …
Buckinghamshire — recommendation GP2-3
To develop practice responses so that individuals are seen alone for at least part of the consultation when indicators of domestic abuse are present in order that any disclosures could be made or routine questioning on domestic abuse undertaken
GP Practice 2
Buckinghamshire — recommendation BCASC-3
Greater emphasis across the service of the principles of Making Safeguarding Personal and ensuring that practitioners enable safe disclosures of domestic abuse during section 42 enquiries, including seeing individuals alone; asking directly about domestic abuse; seen in different settings where possible; consideration given to the use of advocates
Buckinghamshire Council Adult Social Care
Nottingham — recommendation Notts SVS 1
In any situation where clients request online or telephone counselling, however they cannot access a confidential space for counselling, Notts SVS Services will ensure that face-face counselling is delivered in a venue and location that meets the client’s needs e.g., GP, Community Venue, Notts SVS Services counselling rooms. Face-face counselling …
Nottingham Sexual Violence Support Service
Cornwall — recommendation 13
Clinical staff to ensure the service user is asked when they are on their own if they wish their partner to be present in clinical meetings, and staff to document this.
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Lincoln — recommendation 3
Strengthen Patient Autonomy Policies: Review and strengthen policies related to patient autonomy and confidentiality, particularly in situations where family members may be involved in the patient's care. Emphasize the importance of obtaining explicit patient consent for involvement of family members and establish clear guidelines for safeguarding patient autonomy in decision-making …
GP Surgeries
Milton Keynes — recommendation 9
It further recommends around advice disclosing HIV status to new partners. This could be facilitated by GPs and specialist HIV health providers, using this DHR as a case study. A specialist publication or website could be developed to suggest safe ways to carry out these disclosures.
NHS Milton Keynes ICB | Local …
NHS Bedfordshire, Luton and …
Brent — recommendation 7.1.8
Adult patients should be seen alone during their attendance in hospital if there is a safeguarding concern.
London North West Healthcare University NHS …
London North West University …
Monmouthshire — recommendation 9 (a)
Initial interviewing of suspected victims of domestic abuse, whether violence or coercive and controlling behaviour always takes place out of sight and hearing of the suspected perpetrator.
Gwent Police
Gwent Police
Wolverhampton — recommendation 18
The Safer Wolverhampton Partnership to require statutory agencies to demonstrate that within services they provide internally and commission there is a robust policy for providing interpreting services excluding the use of family members or friends except in extreme emergencies.
Safer Wolverhampton Partnership
Southend-on-Sea — recommendation 3
The Southend University Foundation Hospital Trust Emergency Department to review its procedures to ensure environmental privacy is optimised to promote disclosure from patients, particularly those who are in crisis.
Southend University Hospital NHS Foundation Trust
Middlesbrough — recommendation 19.30
Female victims of domestic abuse should be given the opportunity to be interviewed/assessed by a female social worker.
Adult Social Care
Adult Social Services
Croydon — recommendation CHS-R5
Consider means of creating a ‘safe space’ which could be accessed during consultations if required. An example of this would be keeping the weighing and measuring equipment in a separate room. This requires further exploration with maternity and estate colleagues.
Croydon Health Services NHS Trust
Croydon Health Services NHS …
Broxbourne — recommendation 1
Professionals are to be reminded of the importance of holding conversations with individuals who identify as being subjected to domestic abuse, no matter what the circumstances are on presentation. These conversations are to take place in private and to be followed up if the person presenting appears to be under …
All agencies
Cornwall — recommendation 13
Clinical staff to ensure the service user is asked when they are on their own if they wish their partner to be present in clinical meetings, and staff to document this.
NHS Kernow | Cornwall Foundation Partnership …
NHS Kernow
Cumbria — recommendation 4
The Trust must ensure that there is clear guidance to be followed for the care of patients who present as sexually disinhibited, which adheres to national guidance on same sex accommodation.
The Trust
Wiltshire — recommendation 4.2.1c
An easy-to-use interpreting Language Line service/App is available for all clinicians to utilise during their consultations, when English is not the patient’s first language.
Salisbury Medical Practice
Wiltshire — recommendation 4.2.1b
Ensure an interpreting service is available to clinicians when English is not the patient’s first language.
Salisbury Medical Practice
Norfolk — recommendation R14
It is recommended that parents/carers that are potential victims of abuse are seen alone so that they can talk freely about their experiences. This is something that now features in the Domestic Abuse Toolkit (April 2022).
Children's Social Care
Dudley — recommendation UHB_1
Routine enquiry should be asked 3 times throughout pregnancy including the postnatal period when the patient is seen face to face, if the patient attends and is accompanied, staff are to try and create an opportunity and safe space to complete routine enquiry
University Hospitals Birmingham NHS Foundation Trust
University Hospitals Birmingham NHS …
Cumbria — recommendation 7.1.7
NCIC will continue working on the trust initiative—how safe do you feel? and embed it firmly into practice.
North Cumbria Integrated Care NHS Foundation
North Cumbria Integrated Care …
Gloucester — recommendation for GHT maternity st
An anonymised audit of maternity records to be undertaken and results reported to Safer Gloucestershire. Audit methodology must demonstrate that questions have been asked about domestic abuse on two or more occasions antenatally, that risk factors for domestic abuse have been assessed (and addressed if identified) and that the expectant …
Gloucester Hospitals NHS Foundation Trust
Kent — recommendation 13
All agencies are to provide guidance to staff regarding the use of ‘victim blaming’ language within their interaction with victims and also within their written documentation.
All agencies
Leicester — recommendation North Northants Home
Check details of corporate contract for interpretation services in terms of services provided and ability to access translators immediately via a variety of methods. Ensure that staff at all levels have easy and quick access to interpretation services when dealing with a customer whose first language is not English. This …
North Northants Homelessness
Leicester — recommendation Accommodation Concer
Language Line to be used with everyone where English is not a first language.
Accommodation Concern
Leicester — recommendation Sunflower Centre - 5
Further methods of communication should be sought when engaging with non-English speaking victims, including translating text messages and written materials.
Sunflower Centre
Rochford — recommendation 3
Essex Adult Social Care should ensure that: - • Assessments include the views of other relevant persons, carers and family members, and this is recorded. • Where the local authority is to charge for care and support, there has been a financial assessment, of which the person has a copy, …
Essex Adult Social Care
Essex County Council
Nottingham — recommendation 20.3.4
That GP Practices ascertain the patients preferred method of contact (e.g. via telephone, text or letter), when patients register at GP Practices and also when any member of the GP Practice staff reviews patient personal details.
NHS Nottingham City Clinical Commissioning Group
Nottingham City Clinical Commissioning …
Croydon — recommendation CHS-R3
Consideration to be given to the development of posters and/or leaflets which provide information relating to domestic abuse, the Trust’s commitment to supporting victims of abuse and explanation that in view of this, a standard domestic abuse question will be asked of all women during their maternity care. This could …
Croydon Health Services NHS Trust
Croydon Health Services NHS …
Croydon — recommendation CHS-R2
Raise awareness during domestic abuse training around professional curiosity. This should include the potential need for practitioners to create safe situations to speak with patients confidentially if the need arises and potential coercive control and risk is evident.
Croydon Health Services NHS Trust
Croydon Health Services NHS …
South Cambridgeshire — recommendation 27.15
Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) staff to seek consent or refusal of services directly from the patient rather than from relatives. (This guidance is to be included in the Q3 “Learning the Lessons’ bulletin of 2019. The Head of Adult Safeguarding and the Head of Learning and Development …
Cambridgeshire and Peterborough NHS Foundation Trust
Cambridgeshire and Peterborough NHS …
Dudley — recommendation Dudley Group NHS Fou
Raise awareness and accessibility around use of interpreters
Dudley Group NHS Foundation Trust
The Dudley Group NHS …
Fenland — recommendation 8
CGL Cambridgeshire will upskill staff to ensure they are aware of how consensual information sharing can support a service user throughout their treatment journey. Staff will feel confident in explaining and exploring consent with service users, particularly in relation to a change in their risk or circumstances.
Change Grow Live (CGL) Cambridgeshire
Norfolk — recommendation R13
It is recommended that CSC reinforces the guidance and that were appropriate children are seen alone and potentially away from the home to gather their views and that there is a plan of action to achieve this.
Children's Social Care
Sheffield — recommendation 12
Where domestic abuse may be suspected, Professionals should seek to create a safe space (including the use of interpreters as necessary), in order to provide opportunity for vulnerable victims to disclose what may be happening in confidence.
All Agencies
Sefton — recommendation 7
Trust supports patients; we try and reduce the need for patients to go off the Ward for Cigarettes.
Southport and Ormskirk Hospitals NHS Trust
Bradford — recommendation 10
Victims of domestic abuse, or where domestic abuse is considered to be a possibility, will be given the opportunity to speak to professionals alone and in a safe space.
CSC
Civil Service Commission
Tower Hamlets — recommendation A7
Tower Hamlets CAMHS to continue to communicate care plans verbally and by letter copied to GP directly following families attendance at assessment clinics
Tower Hamlets CAMHS
Tower Hamlets Social Services
Lambeth — recommendation R11b
LEO CMHT to develop a protocol to state that relatives and patients are to be given a copy of the treatment care plan on the day of the assessment including crisis contact details
SLaM LEO CMHT
Newham — recommendation 3
The London Borough of Newham and Newham CCG provide publicity and information leaflets for public facing health services on domestic abuse. This should be targeted at immigrant women to ensure they know their rights and that services believe victims of domestic and sexual violence. This will extend to the Open …
London Borough of Newham | Newham …
Newham Council
Croydon — recommendation CHS-R4
Consideration to be given to Midwives asking standard questions in a sensitive manner about experiences of domestic abuse during all antenatal appointments and not just the booking appointment (if safe to do so) and to include in the electronic patient records.
Croydon Health Services NHS Trust
Croydon Health Services NHS …
Islington — recommendation 8
District Nursing team to continue to seek consent from service users and/or have discussion with them before referring to social services. This consent needs to be documented clearly in case files as not to delay referral processes. Additionally, as it is standard procedure to share notes with clients and keep …
District Nursing team
Northumberland — recommendation 22
To encourage practices to implement systems whereby when a partner or family member is requesting access to information, GPs cross reference with the individual’s records where possible to ensure there are no concerns in relation to domestic abuse.
Northumberland Clinical Commissioning Group
NHS Northumberland Clinical Commissioning …
Northumberland — recommendation 13
To ensure concerns of third parties are appropriately followed up on and that this information is not shared directly with those considered to pose the risk, unless this has been explicitly considered and discussed with the third party referrer.
Northumberland, Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Wiltshire — recommendation 4.2.1a
Patients presenting with indicators of possible domestic violence or abuse to be offered a private discussion by an appropriately trained member of the SMP team.
Salisbury Medical Practice
Cheshire West and Chester — recommendation 13.8
With immediate effect, ensure that staff are aware that where possible contact is made with victims directly and not through a 3rd party.
Adult Social Care
Adult Social Services
Cheshire West and Chester — recommendation 13.6b
Within 3 months, where high-risk domestic abuse is identified, General Practitioners are aware of the need to complete a referral, regardless of other agencies involved. They must inform the client when a MARAC referral is made. For lower risk, referrals with consent can be made to support services.
NHS Cheshire Clinical Commissioning Group
Bedfordshire Clinical Commissioning Group
East Sussex — recommendation CGL2
Creative engagement should still be a consideration, whilst following safe practices. Joint visits especially in services where the victim already attends is considered good practice, e.g. GP or Probation. If engagement is not possible the Portal will offer consultation to other professionals where the victim is likely to attend. This …
Change Grow Live Domestic Abuse Portal
Dudley — recommendation Dudley Group NHS Fou
Continue to raise awareness and highlight the need for staff to obtain the wishes and feeling of patients in their care and discharge planning arrangements
Dudley Group NHS Foundation Trust
The Dudley Group NHS …
CQC enforcement actions(8)
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Barts Health NHS Trust following an inspection of Whipps Cross University Hospital's urgent and emergency services in July. CQC found people experienced very long waits in the emergency department, leading …
Whipps Cross University Hospital
Dec 2024
Warning Notice: University Hospitals of Morecambe Bay NHS Foundation Trust
The Care Quality Commission (CQC) issued two formal warning notices to University Hospitals of Morecambe Bay NHS Foundation Trust. Following investigation visits, inspectors found that patients were not always monitored appropriately at the Royal Lancaster Infirmary and Furness General. Additionally, …
Mar 2012
Warning Notice: Chesterfield Royal Hospital NHS Foundation Trust
The Care Quality Commission (CQC) has told Chesterfield Royal Hospital NHS Foundation Trust it must make urgent improvements to comply with the national standards of quality and safety. This follows an unannounced inspection where inspectors found that people were not …
Chesterfield, Derbyshire
Aug 2013
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) conducted an inspection of inpatient wards for people with a learning disability or autistic people at Lanchester Road Hospital and Bankfields Court, operated by Tees, Esk and Wear Valleys NHS Foundation Trust. Following the inspection, …
Lanchester Road Hospital in Durham and Bankfields…
Oct 2022
Warning Notice: Cheshire and Wirral Partnership NHS Foundation Trust
The Care Quality Commission (CQC) served Cheshire and Wirral Partnership NHS Foundation Trust with a warning notice following an inspection in November. The inspection found acute wards for adults of working age and psychiatric intensive care units to be inadequate. …
Mulberry ward in Macclesfield and Brooklands and …
Feb 2023
Conditions Imposed: Portsmouth Hospitals NHS Trust
The Care Quality Commission issued a Warning Notice to Portsmouth Hospitals NHS Trust, requiring improvements in safety, patient consent, dignity and respect, safeguarding, and overall leadership. Concurrently, CQC placed six conditions on the trust's registration, mandating specific actions to ensure …
Queen Alexandra Hospital
Aug 2017
Warning Notice: Barts Health NHS Trust
The Care Quality Commission told Barts Health NHS Trust that it must improve patient care and support given to staff at the Royal London Hospital. This followed an unannounced inspection in June where the hospital was found to be not …
Royal London Hospital
Sep 2013
Warning Notice: Brighton and Sussex University Hospitals NHS Trust
CQC issued a Warning Notice to Brighton and Sussex University Hospitals NHS Trust requiring significant improvements by 30 August in three areas. Inspectors found that the trust's systems to assess, monitor, and minimise risks to people receiving care and treatment …
Brighton and Haywards Heath
Aug 2016