Patient safety governance
Lack of well-protected and defined resources for national patient safety agencies and insufficient awareness among healthcare professionals of the Duty of Candour.
Source spread
Where this theme appears
This theme appears across 20 independent accountability sources, so the source mix matters as much as the headline total.
345 inquiry recs
228 PFD reports
30 committee recs
329 HSSIB recs
972 CQC actions
7 PHSO recs
13 IMB recs
2 patient safety alerts
1 Scottish FAI
5 Article 2 learning points
1 detention investigation rec
32 DHR recs
20 PHSO decisions
444 LGO/SPSO decisions
105 CQC enforcement actions
3 MNSI reports
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(345)— showing 50 strongest matches
40 — Independent specialist advice if in doubt
Recommendation: While hospital managers will usually seek medical advice from the medical director or clinical directors in the first instance, if any substantial doubt remains they shall seek advice from independent specialist medical advisers or the Royal Colleges, whether directly or …
Unknown
39 — Non-medical managers seek medical advice
Recommendation: Hospital managers without medical qualification shall seek medical advice on matters requiring it. If there is doubt as to the need for advice on any matter relating to patient care, the doubt shall be resolved by seeking advice.
Unknown
34 — Report unresolved problems to regional office
Recommendation: If no solution is found after all diligent attempts, the parties should keep records of their attempts and the reasons why they have failed, such records to be lodged by way of report to the relevant NHS Executive Regional Office.
Unknown
33 — Plan to resolve identified problems
Recommendation: Where problems are identified a plan, jointly where necessary, shall be drawn up to resolve them as soon as possible.
Unknown
32 — Investigate failing individuals or departments
Recommendation: Where there is good reason to believe that an individual or department may be failing and affecting patient care, it shall be the duty of the Trust with the co-operation of the university, and if appropriate on a joint basis, …
Unknown
31 — Treat substantial alterations as new
Recommendation: Any substantial alteration in an existing venture shall be treated as if a new venture.
Unknown
29 — Business plan for new ventures
Recommendation: Where a new venture, such as the establishment of a Chair or department, is contemplated, both parties where appropriate shall consider in detail the aims and resources available and draw up a realistic business plan before any final commitment is …
Unknown
27 — Disagreement and patient care
Recommendation: Where there is disagreement each party shall reconsider bearing in mind that patient care is of paramount importance. In the event of continued disagreement an arbitrator may be appointed, but in any case the Trust shall take immediate steps to …
Unknown
20 — Duty to disclose substantial matters
Recommendation: The duty of utmost good faith shall require either party to disclose to the other any substantial matter relating to the performance of the individual or department, whether clinical or academic.
Unknown
16 — Verify container before release
Recommendation: every authorisation for release of organs for burial or cremation must not be completed until the content of the container is confirmed and the form counter-signed;
Unknown
4 — Consider independent incident team
Recommendation: In devising a Serious Incident Procedure the Chief Executive and Trust Board shall consider the need for a serious incident team independent of the hospital.
Unknown
2 — Trust devises incident procedure
Recommendation: In the event of a serious incident the Chief Executive and Trust Board shall devise a suitable Serious Incident Procedure similar to those already in place for major disasters and review it from time to time making any necessary alterations.
Unknown
1 — Develop serious incident procedures
Recommendation: Serious Incident Procedures should be developed and put in place.
Unknown
37 — Permits and isolations remain in force
Recommendation: A permit to work and its consequent isolations, both mechanical and electrical, should remain in force until the work is sufficiently complete for the permit to be signed off and the equipment returned to operation (para 18.8).
Unknown
36 — Mechanical isolation procedure
Recommendation: All permit to work systems should incorporate a mechanical isolation procedure which involves the physical locking off and tagging of isolation valves (para 18.29).
Unknown
34 — Harmonisation of permit to work systems
Recommendation: Standardisation of the permit to work system throughout the industry is neither necessary nor practicable. However, in view of the fact that there is much in common between the systems of different operators, the industry should seek to increase harmonisation, …
Unknown
32 — Permit to work part of the SMS
Recommendation: The operator’s permit to work system should form part of its SMS (para 21.56).
Unknown
28 — Workforce involvement part of the SMS
Recommendation: The operator’s procedures included in line management of operations which are aimed at involving the workforce in safety should form part of its SMS (para 21.56).
Unknown
3 — Safety management system content
Recommendation: The SMS should be in respect of (a) the design (both conceptual and detailed) of the operator’s installations; and (b) the procedures (both operational and emergency) of those installations. In the case of existing installations the SMS in respect of …
Unknown
2 — Objectives the Safety Case must demonstrate
Recommendation: The Safety Case should demonstrate that certain objectives have been met, including the following:- (i) that the safety management system of the company (SMS) and that of the installation are adequate to ensure that (a) the design and (b) the …
Unknown
6 — Monitoring deaths in hospitals
Recommendation: i. By 31 March 2027, all hospital Trusts must have in place effective mechanisms for Board- level monitoring of all deaths of children and babies. ii. By 31 March 2027, all hospital Trusts must have in place a clear and …
Gov response: No formal government response published. The Secretary of State for Health and Social Care's oral statement of 15 September 2026, made on the day the Inquiry's report was published, names neither this recommendation nor board-level …
Unknown
AFA-4 — Governance
Recommendation: The Inquiry recommends a programme of work by the Trust to: • Consolidate governance improvements into a clear, prioritised programme overseen by the Board. This will ensure that the large number of improvement plans do not become overwhelming or get …
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
AFA-2 — Organisational development and cultural reform
Recommendation: The Inquiry recommends that: • The Department should continue to emphasise the importance of cultural change as shown in current work and formally recognise that this contributes to a system wide focus on patient safety as a core system aim. …
Gov response: We fully accept the Inquiry’s findings and recommendations.
Accepted
R81 — Expert clinical governance advisory function
Recommendation: The DoH should establish an expert clinical/social governance advisory function to support providers.
No response yet
R79 — Board member learning framework
Recommendation: The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient …
No response yet
R77 — Triennial Board governance reviews
Recommendation: The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
No response yet
R76 — NED with clinical governance expertise
Recommendation: NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should …
No response yet
R75 — Executive Director of Clinical and Social Care Governance
Recommendation: There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is …
No response yet
F68 — Focus on compliance with fundamental standards
Recommendation: No NHS trust should be given support to make an application to Monitor unless, in addition to other criteria, the performance manager (the Strategic Health Authority cluster, the Department of Health team, or the NHS Trust Development Authority) is satisfied …
Gov response: Accepted. The Board of the NHS Trust Development Authority will only approve a Trust’s application to be passed to Monitor, when it is satisfied that the Trust has clearly demonstrated that it is able to …
Accepted
F67 — Focus on compliance with fundamental standards
Recommendation: The NHS Trust Development Authority should develop a rigorous process for the assessment as well as the support of potential applicants for foundation trust status. The assessment must include as a priority focus a review of the standard of service …
Gov response: Accepted. The focus of the NHS Trust Development Authority is to enable NHS Trusts to provide high quality, sustainable services for their local communities. It does this by overseeing all aspects of a Trust Board’s …
Accepted
F66 — Improving contribution of stakeholder opinions
Recommendation: The Department of Health, the NHS Trust Development Authority and Monitor should jointly review the stakeholder consultation process with a view to ensuring that: Local stakeholder and public opinion is sought on the fitness of a potential applicant NHS trust …
Gov response: Accepted. The NHS Trust Development Authority will test Trusts’ Patient and Public Involvement strategies to ensure they are engaging with their patients and local community throughout the Foundation Trust application process, particularly on the quality …
Accepted
F65 — Quality of care as a pre-condition for foundation trust applications
Recommendation: The NHS Trust Development Authority should develop a clear policy requiring proof of fitness for purpose in delivering the appropriate quality of care as a pre-condition to consideration for support for a foundation trust application.
Gov response: Accepted. The NHS Trust Development Authority has published its Accountability Framework which sets out how Trusts will be held to account for delivering the appropriate quality of care. Trusts which are failing to meet these …
Accepted
F64 — Authorisation of foundation trusts
Recommendation: The authorisation process should be conducted by one regulator, which should be equipped with the relevant powers and expertise to undertake this effectively. With due regard to protecting the public from the adverse consequences inherent to any reorganisation, the regulation …
Gov response: Not accepted, although we agree with the principle of better regulation of the authorisation process. As outlined in relation to recommendation 19, we agree with the principle of better regulation of the authorisation process, but …
Not accepted
F63 — Improved transparency
Recommendation: Monitor should publish all side letters and any rating issued to trusts as part of their authorisation or licence.
Gov response: Accepted. Monitor has published all side letters since 2011 and risk ratings are published on a quarterly basis. Side letters are issued in certain circumstances where an applicant meets the statutory requirements for authorisation but …
Accepted
F62 — Improved patient focus
Recommendation: For as long as it retains responsibility for the regulation of foundation trusts, Monitor should incorporate greater patient and public involvement into its own structures, to ensure this focus is always at the forefront of its work.
Gov response: Accepted. A central theme of Monitor’s Quality Governance Framework is whether the Boards of NHS organisations actively engage patients, staff and other key stakeholders on quality. From April 2013 it is also a licence condition …
Accepted
F61 — Consolidation of regulatory functions
Recommendation: A merger of system regulatory functions between Monitor and the Care Quality Commission should be undertaken incrementally and after thorough planning. Such a move should not be used as a justification for reduction of the resources allocated to this area …
Gov response: Not accepted, although we agee with the principle regarding changes to the regulatory system. While we do not accept this recommendation in the light of the response to recommendation 19, we agree with the principles …
Not accepted
F60 — Consolidation of regulatory functions
Recommendation: The Secretary of State should consider transferring the functions of regulating governance of healthcare providers and the fitness of persons to be directors, governors or equivalent persons from Monitor to the Care Quality Commission.
Gov response: Accepted in principle. However, we believe that the best way to achieve the desired outcome is through closer co- operation between Monitor and the Care Quality Commission rather than through the transfer of functions. The …
Accepted in part
F59 — Care Quality Commission independence strategy and culture
Recommendation: Consideration should be given to the introduction of a category of nominated board members from representatives of the professions, for example, the Academy of Medical Royal Colleges, a representative of nursing and allied healthcare professionals, and patient representative groups.
Gov response: Accepted in principle Steps have already been taken by Care Quality Commission to establish a series of sector specific advisory groups, which include senior representatives from Royal Colleges and patient groups. These groups support the …
Accepted in part
F58 — Care Quality Commission independence strategy and culture
Recommendation: Patients, through their user group representatives, should be integrated into the structure of the Care Quality Commission. It should consider whether there is a place for a patients' consultative council with which issues could be discussed to obtain a patient …
Gov response: Accepted. The Care Quality Commission uses a wide range of means to engage people who use services in its work. It is holding a number of events and activities to ask people how they it …
Accepted
F57 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should undertake a formal evaluation of how it would detect and take action on the warning signs and other events giving cause for concern at the Trust described in this report, and in the report of …
Gov response: Accepted. The Care Quality Commission has carried out a significant review of how it uses information to identify potential failures in the quality of care in hospitals. Taking each of five key questions – is …
Accepted
F56 — Care Quality Commission independence strategy and culture
Recommendation: The leadership of the Care Quality Commission should communicate clearly and persuasively its strategic direction to the public and to its staff, with a degree of clarity that may have been missing to date.
Gov response: Accepted. In April 2013 the Care Quality Commission published its new three year strategy, Raising Standards, putting people first – our strategy 2013–16.54 This document sets out how the Care Quality Commission will make major …
Accepted
F55 — Care Quality Commission independence strategy and culture
Recommendation: The Care Quality Commission should review its processes as a whole to ensure that it is capable of delivering regulatory oversight and enforcement effectively, in accordance with the principles outlined in this report.
Gov response: Accepted. The Care Quality Commission has begun implementing a new approach to inspection and enforcement that is fundamentally different. It has appointed chief inspectors to lead this new approach in each sector. Key means of …
Accepted
F54 — Care Quality Commission independence strategy and culture
Recommendation: Where issues relating to regulatory action are discussed between the Care Quality Commission and other agencies, these should be properly recorded to avoid any suggestion of inappropriate interference in the Care Quality Commission's statutory role.
Gov response: Accepted. The Care Quality Commission is implementing this recommendation by means of partnership agreements and operational protocols which include criteria to make and store a formal record of meetings. So far, these cover the Care …
Accepted
F53 — Care Quality Commission independence strategy and culture
Recommendation: Any change to the Care Quality Commission's role should be by evolution – any temptation to abolish this organisation and create a new one must be avoided.
Gov response: Accepted. There are no plans to abolish the Care Quality Commission. The Care Quality Commission has set out a new strategy for the next three years, and has a new Board in place, with five …
Accepted
F52 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should consider whether inspections could be conducted in collaboration with other agencies, or whether they can take advantage of any peer review arrangements available.
Gov response: Accepted. The Care Quality Commission is developing Memoranda of Understanding with medical, nursing and midwifery Royal Colleges. These will ensure that peer review and accreditation schemes are taken fully into account as new methods of …
Accepted
F51 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should develop a specialist cadre of inspectors by thorough training in the principles of hospital care. Inspections of NHS hospital care providers should be led by such inspectors who should have the support of a team, …
Gov response: Accepted. The Chief Inspector of Hospitals has begun inspecting in this way. Useful lessons were learnt from the Care Quality Commission’s targeted inspections of 150 learning disability in-patient units following events at Winterbourne View hospital; …
Accepted
F50 — Enhancement of monitoring and the importance of inspection
Recommendation: The Care Quality Commission should retain an emphasis on inspection as a central method of monitoring non-compliance.
Gov response: Accepted. The Care Quality Commission has introduced a fundamentally different and strengthened approach to inspection as the centrepiece of how it assures standards of care. The Care Quality Commission’s new approach to inspection involves large …
Accepted
F49 — Enhancement of monitoring and the importance of inspection
Recommendation: Routine and risk-related monitoring, as opposed to acceptance of self-declarations of compliance, is essential. The Care Quality Commission should consider its monitoring in relation to the value to be obtained from: The Quality and Risk Profile; Quality Accounts; Reports from …
Gov response: Accepted. The Care Quality Commission is fundamentally changing the way it monitors providers on the quality of their services. Through its Chief Inspector of Hospitals, it has introduced a new system in the hospital sector. …
Accepted
F48 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should send a personal letter, via each registered body, to each foundation trust governor on appointment, inviting them to submit relevant information about any concerns to the Care Quality Commission.
Gov response: Accepted in principle. Professor Sir Mike Richards, the Chief Inspector of Hospitals, has already written to Foundation Trust Councils of Governors about the first wave of his new NHS Trust inspections, setting out how Councils …
Accepted in part
F47 — Use of information about compliance by regulator from: Foundation trust governors and scrutiny committees
Recommendation: The Care Quality Commission should expand its work with overview and scrutiny committees and foundation trust governors as a valuable information resource. For example, it should further develop its current 'sounding board events'.
Gov response: Accepted. The Care Quality Commission has taken steps to engage Overview and Scrutiny Committees and Foundation Trust Governors, to increase their input to its new approach to inspection and monitoring. All Overview and Scrutiny Committees …
Accepted
Prevention of Future Deaths reports(228)— showing 50 strongest matches
Bertha Cray
Concerns: The coroner notes the potential for 'nil by mouth' signage to be inadvertently altered due to the design of double-sided signs and the lack of clarity regarding the cause of a past alteration, raising a risk of recurrence.
Response (Barts Health NHS Trust): • The Trust concluded its investigation into the concerns regarding 'nil-by-mouth' signs. • The Trust confirmed that the use of double-sided 'nil-by-mouth'/'sips of water' signs was not standard practice. • … (AI summary)
Responded
Kirabo Kiwanuka
Concerns: The coroner noted a lack of agreement among senior professionals on diagnosing and managing NMS, and uncertainty about the optimal care model for acutely manic patients with physical illness. There were also concerns about limited family involvement in best interest decisions for sectioned patients.
Overdue
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends pose an increased risk of post-operative complications for vulnerable patients.
Overdue
Barry Dillion
Concerns: Insufficient resources for the Speech and Language Therapy service at Royal Blackburn Hospital lead to delays in swallow assessments, increasing the risk of aspiration pneumonia for patients.
Overdue
Nellie Travis
Concerns: The coroner noted the hospital's Falls Risk Assessment tool was subjective and its utility depended on individual nurse opinion, especially when completed by non-Trust staff. A more objectively assessed tool was identified as necessary.
Overdue
Stephen Ellis
Concerns: The coroner suggested it would be good practice to supply warfarin home management kits to high-risk patients who have undergone heart surgery and are subsequently on warfarin.
Overdue
Neil Carter
Concerns: The coroner noted repeated failures to perform basic nursing observations, inadequate staffing levels and skill mix on the ward, and a lack of staff discipline. There was also a deliberate falsification of nursing records.
Response (CQC): • The CQC conducted multiple inspections of The Priory Hospital Roehampton, identifying non-compliance in areas such as staffing and observation training, and requiring the provider to take action. • Subsequent … (AI summary)
Response (Priory Group): • The individual responsible for record falsification and missing observations was dismissed and referred to the Nursing and Midwifery Council. • The hospital implemented changes to staff induction, reviewed its … (AI summary)
Responded
Natasha Raghoo
Concerns: The coroner noted insufficient staff training in resuscitation, sporadic physical observations which ceased prematurely, and the lack of an electrocardiogram despite clinical need. Inconsistent staff handovers and unclear communication policies were also identified.
Response (Partnership in Care): • A programme of monthly emergency incident drills was implemented, and a company-wide training programme for Immediate Life Support, including defibrillator use, was delivered to qualified nurses and doctors. • … (AI summary)
Overdue
Jean James
Concerns: The coroner identified delays in initial documentation, an unreviewed omission of prophylactic Dalteparin, and ineffective communication of a pharmacy query. Concerns were also raised that existing systems and policies may not be robust enough to manage human factors.
Response (City Hospitals Sunderland): • The Trust reviewed its hospital information system (MEDITECH V6) and is implementing updates to automatically prompt VTE medication prescriptions and alerts. • The Trust introduced a new patient-focused format … (AI summary)
Responded
John Adams
Concerns: VERONICA HAMILTON-DEELEY, LLB.
Overdue
Lana-Liza Chervonenko
Concerns: Insufficient medical cover and high activity on the labour ward led to delays in patient review, documentation errors, and communication gaps between clinical teams. The coroner also noted no system existed for theatre staff to proactively notify treating teams of theatre availability.
Overdue
Ronald Smith
Concerns: The coroner noted the absence of a clear and accessible protocol for staff to access equipment for flexible sigmoidoscopies out of hours. This issue persisted 18 months after the death, indicating a need for expedited action.
Overdue
Anthony Geerts
Concerns: The provided text is incomplete and does not contain any discernible coroner's concerns.
Response (Brighton and Sussex University Hospitals NHS Trust): • The trust centralised the fractured neck of femur service at Princess Royal Hospital, eliminating patient transfers between sites. • A Clinical Nurse Practice Educator was recruited, integrated documentation introduced, … (AI summary)
Overdue
Karen O’Brien
Concerns: The coroner noted concerns regarding a clinical determination made by SEPT without a face-to-face mental health assessment or sufficient inquiry, overriding the patient's GP's request. The report also invited NICE to reconsider its guideline on this matter.
Overdue
Mary James
Concerns: The coroner noted inadequate monitoring of INR levels and uncertainty regarding Warfarin adherence for a patient with dementia. There were also concerns about communication gaps between the INR Unit, care home, and GP, and a missed opportunity for hospital admission to adjust anticoagulation therapy.
Overdue
Eileen Smith
Concerns: Failings in nursing care were identified for a patient with learning disabilities, alongside inadequate communication with their carers and family. The report also raised concerns about assumptions made regarding the health of individuals with learning disabilities.
Response (Department of Health): • The Trust carried out a Serious Incident Investigation, produced a report detailing failings, and implemented an action plan with changes to prevent recurrence. • The Trust produced a hospital … (AI summary)
Responded
Barry Pike
Concerns: The coroner's specific concerns are detailed within an enclosed report authored by Dr Stephen Hoole, which was referenced in the PFD.
Overdue
Sharon Henshall
Concerns: The coroner identified the absence of a venothromboembolism risk assessment model in the Emergency Department for patients discharged with lower limb immobilisation, noting a 'postcode lottery' in prophylaxis across different Trusts and inconsistency with NICE guidance.
Overdue
Frederick Sutton
Concerns: The coroner identified suboptimal hospital staffing levels, issues with staff shortage escalation procedures, and insufficient staff training in drug administration and cardiac arrest response.
Overdue
Rosalind Baird
Concerns: The coroner noted a lack of a formal national monitoring scheme for inexperienced surgeons carrying out procedures. Consideration should be given to developing a national scheme, using the Queen Alexandra Hospital's model as an example of good practice.
Overdue
Rebecca Jones
Concerns: The coroner identified that the Section 136 assessment for Rebecca Jones was not conducted within the expected three-hour timeframe. This delay occurred because urgent assessments were required for other vulnerable persons, indicating a potential capacity issue at the facility.
Response (Department of Health): • NHS England committed to spending £15 million in 2016/17 to boost provision and improve standards in health-based places of safety. • NHS England stated it would develop commissioning guidance … (AI summary)
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Darren Jones
Concerns: Current protocols for when to seek renal advice for patients, particularly those who have undergone transplants, are limited, and there are questions regarding the availability of immunosuppressant medication at short notice.
Overdue
Thelma Clarkson
Concerns: The coroner noted that the NICE Head Injury Pathway does not include Clopidogrel as a trigger for a CT scan after a head injury, unlike Warfarin, despite the increased risk of bleeding. This omission may affect timely diagnosis and treatment.
Overdue
Stephen Adams
Concerns: The coroner noted that the suicide risk assessment section on the Mental Health Liaison Team's risk assessment document was frequently left incomplete, requiring risk to be inferred from actions rather than explicitly recorded.
Overdue
Bryan Catanach
Concerns: The coroner raised concerns about communication difficulties between clinicians and hospital trusts, leading to delayed patient transfers and reviews. Issues also included a patient falling from bed due to inadequate supervision for an unstable neck fracture.
Response (Bryan Catanach): • The Trust refreshed and reaffirmed its receiving and first line management processes for emergency patients, including piloting a 'consultant of the week' model for spinal services. • Proforma-based documentation … (AI summary)
Responded
Lincoln Brady
Concerns: The coroner noted that non-correlating examination results were not further investigated with an ultrasound, leading to an undiagnosed breech presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): • The Trust implemented 'Lincoln's Rule' in January 2015, establishing a low threshold for considering presentation scans and highlighting red flags for further investigation. • Policies and training for managing … (AI summary)
Responded
June Parkes
Concerns: Deficiencies in provision and protocols for urgent and emergency endoscopies and surgery were identified. Concerns also included staff compliance with the NEWS system, record-keeping, and criteria for doctor presence during critical patient transfers.
Overdue
Alwyn Head
Concerns: The coroner noted concerns regarding the patient's MRSA history not being established pre-surgery, and a lack of prophylactic medication. There was no post-operative wound care plan, insufficient surgical wound inspection, and inadequate documentation of wound status.
Response (A head): • New admission/transfer assessment documentation for patient infection status was introduced, with staff training and daily monitoring by the infection control team. • Orthopaedic antimicrobial guidelines were updated, and the … (AI summary)
Responded
Dorothy Imisson
Concerns: The coroner identified that the District Nursing Service did not develop an appropriate care plan and did not adhere to NMC guidance on record-keeping or NICE clinical guidelines.
Overdue
Milly Zemmel
Concerns: The Trust's internal investigation did not fully identify failures in basic medical care, including a lack of appropriate one-to-one supervision for a patient with acute confusion and blindness, and inadequate information handover between shifts.
Response (Response Pennine Acute Hospitals): • The Trust revised its Incident Reporting and Investigation Policy in June 2015, establishing independent investigation teams and providing root cause analysis training. • A 'Safety Huddle' was introduced for … (AI summary)
Responded
Amanda Coulthard
Concerns: The coroner noted multiple avoidable deaths from misplaced nasogastric tubes, linked to staff non-compliance with policy, inadequate training, and insufficient audits. Concerns also included the Trust's failure to learn from prior incidents and implement national alerts.
Response: • The Department of Health highlighted the July 2016 Patient Safety Alert, which requires NHS Boards to assess and address compliance with safe nasogastric tube placement by April 2017. • … (AI summary)
Response (North Cumbria University Hospitals Trust): • The Trust provided a report summarising actions taken against the five specific actions in the Regulation 28 Notice. • The Trust committed to implementing additional identified actions over the … (AI summary)
Responded
Michael Parke
Concerns: The coroner noted recurring deaths from misplaced nasogastric tubes, citing staff non-adherence to policy, inadequate training, and the Trust's failure to address prior issues. Concerns were also raised about the lengthy and error-prone policy document.
Response: • NHS Improvement issued a Patient Safety Alert in July 2016, requiring NHS Trust Boards to assess and address compliance issues related to nasogastric tube placement by April 2017. • … (AI summary)
Response (North Cumbria University Hospitals Trust): • The Trust stated it had taken action against the five specific actions outlined in the Regulation 28 Notice. • The Trust indicated it would implement additional identified actions over … (AI summary)
Responded
Kathleen Cooper
Concerns: The coroner identified challenges to patient safety arising from split-site commitments and out-of-hours care. Recurring errors in patient management were noted, including poor communication, inadequate supervision, issues with early warning scores, and a failure to escalate deterioration, with insufficient progress made on addressing these issues.
Overdue
Anna Walker
Concerns: The coroner noted inadequate post-operative monitoring, unclear clinical accountability between departments, and an ongoing issue with patient transfer by porters. Concerns were also raised that the initial incident report's findings conflicted with expert evidence regarding care.
Overdue
Annette Krasinsky-Lloyd
Concerns: The coroner identified inadequate supervision for the SHO, delays in consultant engagement, obtaining test results, and administering critical treatments. There were also concerns regarding insufficient patient monitoring in the A&E department.
Overdue
Caliel Smith-Kwami
Concerns: Delayed insulin results and a lack of clinician notification about analyser faults were identified, alongside critical test results not being chased up or highlighted within the electronic record system before discharge.
Response (Barts Health NHS Trust): • The Laboratory underwent a UKAS inspection and was recommended for accreditation; contingency plans for analyser faults have been reviewed and approved. • A system has been developed where a … (AI summary)
Responded
Barry Tucker
Concerns: No specific concerns were detailed in the provided text.
Response (East Sussex Healthcare NHS Trust): • The Trust amended job plans to include daily consultant rounds and updated post-operative daily round documentation. • The Trust advised the private patient unit not to accept bookings for … (AI summary)
Responded
Frank Hayward
Concerns: The coroner identified failures in the Emergency Department to correctly assess and diagnose injuries and missed opportunities for earlier specialist review. There were also poor systems for providing a collar, communication issues, and delays in obtaining a CT scan.
Response (Frank Hayward): • The guideline for head injury diagnostic testing and treatment has been revised in line with NICE Clinical Guideline (CG176). • Trauma & Orthopaedics clinicians have been trained in applying … (AI summary)
Responded
Lea Hunsley
Concerns: The EAM facility lacked a serious untoward incident protocol, and staff demonstrated insufficient ability to identify deteriorating patients, escalate medical reviews, or use care records effectively. Insufficient action had been taken on recommendations from a CQC inspection, without sustained improvement.
Response (EAM Care Group): • A Serious Untoward Incident Reporting Policy and a Duty of Candour policy have been implemented. • Staff have undertaken clinical observation training, and nurse managers have been trained to … (AI summary)
Responded
Marian Grant
Concerns: The coroner raised concerns regarding the omission of VTE prophylaxis due to EPR technical difficulties, particularly for trauma patients cared for on non-trauma wards, and that VTE prophylaxis alerts on EPR were frequently not seen by medical staff.
Response (Marion Grant): • The Trust implemented a new system where doctors cannot exit the Electronic Patient Record until a VTE prophylaxis alert has been actioned and the drug prescribed. • A Clinical … (AI summary)
Responded
Hubert Kelly
Concerns: Nursing staff lacked space and resources for patients after triage, leading to waits in corridors with no meaningful interaction or permanent medical staff. Emergency department waiting times frequently exceeded national targets, with some patients waiting up to seven hours.
Response (Hubert Kelly): • The Trust implemented a nationally recognised triage tool, expanded its triage area, and introduced a process for quickly performing patient observations during high demand. • A 24/7 Clinical Support … (AI summary)
Overdue
Rita Giles
Concerns: The coroner noted concerns regarding unnecessary patient transfers to and from the Princess Royal Hospital, which were carried out without supporting paperwork.
Overdue
Ronald Harman
Concerns: The coroner noted that Brighton & Sussex University Hospitals NHS Trust's Transfer Policy was not adhered to, and care provided at Newhaven Downs was suboptimal.
Overdue
John Waite
Concerns: The hospital's central venous catheter removal policy and updated guidance were insufficient as they did not require constant visual observation, risking significant blood loss between intermittent checks. There is also an absence of national guidelines for central venous catheter removal.
Response (John Waite Response2): • The Trust established a task and finish group to review central venous catheter (CVC) policies and develop guidance, including a quick reference guide for haemodialysis CVC removal. • Guidance … (AI summary)
Response (John Waite): • An advisory alert has been issued to renal units in England, asking them to review current practices for central venous catheter removal, with specific attention to precautions and patient … (AI summary)
Overdue
Angela Jackson
Concerns: The coroner identified a lack of clear, written protocols or pathways for the treatment and urgent referral of aortic aneurysms in the North West, noting confusion with hospital names and the absence of clear guidance for healthcare professionals.
Response (Angela Jackson): • Liverpool Heart and Chest Hospital NHS Foundation Trust developed and published the Liverpool Acute Network for Thoracic Aortic Services (LANTAS) pathway, distributing it regionally and placing it on its … (AI summary)
Response (Angela Jackson Response2): • Existing service specifications for vascular surgery outline networked arrangements and pathways for specialised vascular services. • Work has been commissioned for national cardiac and vascular clinical reference groups to … (AI summary)
Overdue
Stephen Taylor
Concerns: The coroner identified a lack of consultant physician support for neurosurgical patients, especially for junior doctors implementing alcohol withdrawal regimens, and a difficult-to-understand alcohol withdrawal protocol that led to incorrect medication.
Response (Stephen Taylor): • The Trust has an electronic referral system in place for medical staff to seek opinions from different specialties. • Junior doctors rotate through various medical specialties to develop competencies … (AI summary)
Responded
Mary Ryder
Concerns: The national guidance for Clexane prescription after an operation does not account for patients with prolonged reduced mobility, nor does it emphasize reviewing their needs post-discharge.
Response (Department of Health Social Care): • NICE considered the concern raised regarding its guidelines on venous thromboembolism. • NICE concluded that its guidelines do not require amendment. • NICE stated that its existing guidelines make … (AI summary)
Responded
Joseph Page
Concerns: The coroner identified that Patients' Own Drugs (PODS) were left unsecured in the Emergency Department and on wards, risking misuse or theft. Concerns were also raised about policies not being followed and an unclear timeline for the implementation and staff awareness of updated policies.
Overdue
John Kirby
Concerns: The report indicates a risk of future deaths, but specific concerns are not detailed in the provided text.
Response (Sussex NHS Trust): • The Trust confirmed a significant reduction in the Lead Practitioner's caseload, with robust and ongoing review and supervision. • An information sharing protocol was established between the Mental Health … (AI summary)
Overdue
Select committee recommendations(30)
#9 —
Recommendation: NHS England must identify how many patients have become unwell or have been harmed because of a failure in homecare services. They should ensure that this information is published and shared with relevant parties. It should also form part of …
Response attribution not verified
#8 —
Recommendation: No one—not the Government, not NHS England, not patient groups, not regulators, knows how often, nor how seriously patients suffer harm from service failures in homecare. This indicates a significant failure of oversight and hinders the ability of NHS England …
Response attribution not verified
#5 —
Recommendation: Delays in providing homecare services can negatively impact on patients physical and mental health. For some, impacts can be serious safety issues and include patients being admitted to hospital or requiring surgery.
Response attribution not verified
#17 — Department fails to outline specific actions for reducing patient harm and improving safety.
Recommendation: The previous Committee were concerned that the Department was spending billions of pounds of taxpayers’ money without an effective plan to minimise future costs of the clinical negligence scheme.25 In April 2024, the Committee recommended that, by summer 2024, “the …
Response attribution not verified
#4 — Develop a plan to reduce patient harm and manage escalating clinical negligence costs.
Recommendation: It is unacceptable that the Department is yet to develop a plan to deal with the cost of clinical negligence claims, and so much taxpayers’ money is being spent on legal fees. The Department has set aside an astounding £58.2 …
Response attribution not verified
#15 — Lack of centralised learning causes repeated patient safety incidents across trusts.
Recommendation: Written evidence submitted to us raised concerns about a lack of centralised learning leading to incidents being repeated across multiple trusts.31 When asked what it was doing to improve systemic learning from patient safety incidents, NHS England told us it …
Response attribution not verified
#13 — Health system overwhelmed by patient safety recommendations, hindering affirmative action.
Recommendation: In 2024, the Health Services Safety Investigations Body reported that the broader health system was drowning in patient safety recommendations rather than taking affirmative actions to improve it.26 NHS England told us that there are over 1,500 recommendations in the …
Response attribution not verified
#10 — Patient safety system suffers from duplication and minimal improvement amidst reforms.
Recommendation: The NHS reports around 2.4 million patient safety incidents annually, most of which (70%) cause no harm to patients, but around 0.5% of patient safety incidents result in severe harm or death. The 2025 Dash review identified considerable overlap and …
Response attribution not verified
#2 — Establish a national framework for patient safety with clear targets and improved complaints system.
Recommendation: The NHS has not done enough to tackle the underlying causes of harm to patients. The Department and NHS England’s approach to patient safety lacks coordination. Patients often pursue legal action to get answers and accountability due to a confusing …
Response attribution not verified
#4 — Publish the Amos Review and outline concrete plans to reduce maternity care harm and costs.
Recommendation: The Department’s failure to address problems with maternity care in England has led to avoidable harm and unnecessary costs. Over the last 20 years the cost of settling claims involving infants and children has increased significantly. In 2024–25, costs for …
Response attribution not verified
#25 —
Recommendation: The Mental Health Bill should be amended to ensure that the Human Rights Act, and the protection it provides, applies whenever people receive publicly funded mental health treatment or after–care, or are deprived of their liberty on mental health grounds. …
Response attribution not verified
#24 —
Recommendation: The Human Rights Act provides legal protection against, and redress for, human rights violations in the UK. Recent case law has highlighted a gap in that human rights protection for mental health patients in state commissioned but privately provided care. …
Response attribution not verified
#73 —
Recommendation: Comprehensive analysis should be carried out to assess the safety of running the NHS with the limited latent capacity that it currently has, particularly in Intensive Care Units, critical care units and high dependency units.
Response attribution not verified
#12 —
Recommendation: We again recommend that the Care Quality Commission includes consultation with patient groups and details of patient outcomes in its assessment of ICSs. (Paragraph 68) Funding and policies to tackle the backlog
Response attribution not verified
#8 — High-value maternity brain injury claims drive significant clinical negligence costs.
Recommendation: NHS Resolution told us that clinical negligence is putting pressure on NHS budgets and is a significant cost to the public purse. The Department told us the reasons for the rising costs were complex. NHS Resolution explained that the increasing …
Response attribution not verified
#4 —
Recommendation: We recommend that the CQC’s assessment of ICSs includes consultation with patient groups and consideration of patient outcomes, and that all relevant data is published.
Response status not verified
#1 —
Recommendation: We support the proposals in the White Paper that will be included in the new Bill and welcome the direction of travel in the Government’s reform of health and social care. Provided that proper accountability mechanisms are put in place, …
Response status not verified
#31 —
Recommendation: It is deeply concerning that maternity units appear to have been penalised for high Caesarean Section rates. We recommend an immediate end to the use of total Caesarean Section percentages as a metric for maternity services, and that this is …
Response attribution not verified
#23 —
Recommendation: England remains a largely safe place to give birth and efforts to increase the safety of maternity services have led to further improvements. However, the Expert Panel overall rated the Government’s progress on maternity safety outcomes as ‘Requires Improvement’. The …
Response attribution not verified
#71 —
Recommendation: The experience of the demands placed on the NHS during the covid-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS.
Response attribution not verified
#71 —
Recommendation: The experience of the demands placed on the NHS during the covid-19 pandemic should lead to a more explicit, and monitored, surge capacity being part of the long term organisation and funding of the NHS.
Response attribution not verified
#6 — Set out how NHSE and NHS Supply Chain will involve clinicians in purchasing decisions.
Recommendation: NHSE and NHS Supply Chain have not convinced clinicians that they value the quality of products above price. We are concerned that a focus on costs may impact on the quality of outcomes for patients. We can see the value …
Response attribution not verified
#2 — Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
Recommendation: In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in …
Gov response: Partially accept. The Department partially accepts this recommendation. We recognise that some people are facing challenges trying to access general practice services in a timely way, and general practice teams have been working immensely hard …
Accepted in Part
#1 — General practice in crisis due to poor patient access and safety risks, unacknowledged by government.
Recommendation: The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has …
Response attribution not verified
#35 —
Recommendation: In addition to the recommendations on data we set out in our report on the treatment of autistic people and people with learning disabilities, we further recommend that NHS England and Improvement regularly collect and publish high quality data including …
Response attribution not verified
#34 —
Recommendation: It is vitally important to be able to monitor the experiences of children and young people in inpatient care, particularly how often restraint is used in each setting and whether there is appropriate access to advocacy. This is key to …
Response attribution not verified
#11 —
Recommendation: Lastly, we heard that patient involvement in services was important to tackle long covid. It should also be taking place in other areas. We have previously called for the Care Quality Commission’s assessments of Integrated Care Systems (ICSs) to include …
Response attribution not verified
#9 —
Recommendation: We recommend that NHS England undertake a review of the role of targets across the NHS which seeks to balance the operational grip they undoubtedly deliver to senior managers against the risks of inadvertently creating a culture which deprioritises care …
Response attribution not verified
#25 — Trusts primarily responsible for RAAC risk management, despite some national technical support.
Recommendation: We asked whether NHS trusts were getting adequate help from national bodies given the risks they had to manage. NHS England told use that it was helping trusts to source the right technical support, but trusts themselves were responsible for …
Response attribution not verified
#15 — Require the New Hospital Programme to conduct comprehensive live clinical testing of Hospital 2.0 designs.
Recommendation: Before the evidence session, we visited a “super hospital” project in Denmark. The Danes had built a prototype of a new operating theatre on the edge of an existing hospital and each surgical team was given access to it so …
Response attribution not verified
HSSIB safety recommendations(329)— showing 50 strongest matches
Electronic patient record systems – electronic referrals for ongoing care
Organisations can improve patient safety by ensuring the mandated requirements for digital clinical risk management (under DCB0160) for the deployment of the electronic referral service (e-RS) are achieved. For general practices and integrated care boards this includes agreeing responsibilities for …
Safety Observation
Electronic patient record systems – electronic referrals for ongoing care
HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of advice and guidance processes, including as part of single point of access. This is in order to address the varying risks to patient safety created …
Safety Recommendation
Digital tools for online consultation in general practice
HSSIB recommends that NHS England develops mechanisms for assuring that integrated care boards support general practices when implementing online consultation. This is to ensure online consultation tools are procured and implemented in ways that best support patient safety.
Safety Recommendation
Digital tools for online consultation in general practice
HSSIB recommends that NHS England undertakes an evaluation of the risks to patient safety of online consultation tools in general practice, taking into account the findings of this investigation, recent research, and the experiences of general practices. This is to …
Safety Recommendation
Temporary staff – involvement in patient safety investigations
HSSIB recommends that NHS England updates the agency worker framework agreement criteria to explicitly require framework agreements to adhere to the staff support principles of the NHS England Patient Safety Incident Response Framework. This will improve patient safety as there …
Safety Recommendation
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and oversight roles and responsibilities specification in oversight processes to highlight where further support and resource is needed to meet the expectations under PSIRF.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and oversight roles and responsibilities specification to assess organisational support and where further resource is needed for PSIRF implementation.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and national guidance on engaging and involving those affected to assess practice and identify where additional resource and support is needed.
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation proactively identify new and emerging risks associated with an EPR system, and ensure these are reviewed and mitigated as far as is practicable?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation manage and oversee configuration changes to EPR systems to ensure they are appropriate, safe and successful?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
Does your organisation understand the expectations for clinical risk management of health IT systems in relation to deployment, ensuring these are met and regularly reviewed?
Learning Prompt
Patient care in temporary care environments
Does your organisation gather information about the use of temporary care environments including: the patient cohorts using temporary care environments a description of the temporary care environment how long patients have been in a temporary care environment incidents that have …
Learning Prompt
Patient care in temporary care environments
Has your organisation nominated and assigned an individual healthcare professional to oversee temporary care environments, who is responsible for managing the completion of regular patient observations, escalating concerns, and standing back and providing leadership and supervision without being involved in …
Learning Prompt
Patient care in temporary care environments
Does your organisation have a policy that governs the use of temporary care environments that includes potential risk mitigation strategies? Do these policies consider the severity of patients’ health conditions, the appropriateness of patients who can be assigned to a …
Learning Prompt
Patient care in temporary care environments
NHS regional and national organisations can improve patient safety by enhancing understanding of the use of temporary care environments across all hospital settings. This may include agreeing definitions of temporary care environments and enhanced information gathering on their use and …
Safety Observation
Insulin: supporting safe administration in inpatient settings
HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement …
Safety Recommendation
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including …
Safety Recommendation
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance …
Safety Recommendation
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.
Safety Observation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by ensuring the sharing of safety learning about electronic prescribing and medicines administration (ePMA) functionality nationally via incident reporting systems and relevant safety forums.
Safety Observation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers can improve patient safety by applying the standards and expectations for a medical device when developing electronic prescribing and medicines administration (ePMA) functionality, to help provide further assurance to acute hospital trusts procuring or updating ePMA functionality.
Safety Observation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that the Medicines and Healthcare products Regulatory Agency ensures that: routes for manufacturers and healthcare organisations to engage with them are clear and accessible it reviews and provides further guidance and clarification on when electronic prescribing and medicines …
Safety Recommendation
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure shared governance forums are appropriately established and resourced, and are effective?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you consider relevant tools and guidance when developing work processes across different organisations?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and mitigate potential harm caused when implementing a new care pathway?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure that implementation of a care pathway is effectively evaluated to improve safety and learning?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and mitigate unexpected challenges to patient safety arising from the care pathway’s implementation?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure appropriate tools and resources are used to support the design and implementation of the care pathway?
Learning Prompt
Online prescribing: challenges and opportunities to improve patient safety
Independent prescribing organisations can improve patient safety by ensuring that patient information contained in the NHS App is not used as a sole source of verification when making clinical decisions, as this is outside the purpose of the App and …
Safety Observation
Implantation of wrong prostheses during joint replacement surgery
NHS Improvement amends the national Prosthesis Verification Standard to incorporate the specific aspects of verification practice developed to mitigate error identified in this investigation.
Safety Recommendation
Insertion of an incorrect intraocular lens
The Royal College of Ophthalmologists establish an expert working group to evaluate the variance of practice for cataract surgery, and subsequently establish standardised and workable processes to minimise the risk that a patient will receive an incorrect intraocular lens.
Safety Recommendation
Insertion of an incorrect intraocular lens
The Department of Health and Social Care commissions a set of standards for the NHS that utilises appropriate technologies to provide digital alerts when incorrect intraocular lens are selected.
Safety Recommendation
Piped supply of medical air and oxygen
The National Patient Safety Alert Committee should set standards for all issuers of patient safety alerts that require an assessment for unintended consequences, the effectiveness of barriers in the alert, and the advice the alert issuers give providers on implementation …
Safety Recommendation
Inadvertent administration of an oral liquid into a vein
It is recommended that the Royal College of Physicians, in collaboration with the Royal Pharmaceutical Society, British Pharmacological Society, Royal College of General Practitioners, Royal College of Paediatrics and Child Health, NHS Improvement, the professional bodies for the professions regulated …
Safety Recommendation
Inadvertent administration of an oral liquid into a vein
It is recommended that NHS Improvement undertake a formal evaluation of banding, time and resource given to the Medication Safety Officer role across England and publish its findings and mandate minimum resources and standards.
Safety Recommendation
Inadvertent administration of an oral liquid into a vein
It is recommended that NHS Improvement support the development of necessary knowledge, skills and capacity for the effective operationalisation of hazard identification and risk analysis at a national, regional and local level, as an integral part of the National Patient …
Safety Recommendation
Electronic prescribing and medicines administration systems and safe discharge
National, peer-reviewed, standardised lists of alerts for clinical decision support systems should be the gold standard, to enable consistency of approach and to promote evidence-based safety improvements. Decision support systems in sectors other than healthcare
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
It would be beneficial to the users of electronic prescribing medicines and administration systems if the system vendors raised awareness of the safety limitations of their products and had a system for collating safety feedback to inform future development and …
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHSX continues its assessment of the ePRaSE pilot and considers making ePRaSE a mandatory annual reporting requirement for the assessment and assurance of electronic prescribing and medicines administration safety.
Safety Recommendation
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHSX develops a process to recognise and act on digital issues reported from the Patient Safety Incident Management System.
Safety Recommendation
Lack of timely monitoring of patients with glaucoma
It is recommended that NHS England and NHS Improvement commission NHS Digital to publish reports of hospital eye services’ compliance with the follow-up appointments performance standard included in the Portfolio of Indicators for Eye Health and Care.
Safety Recommendation
Lack of timely monitoring of patients with glaucoma
It is recommended that NHS England and NHS Improvement require commissioners to agree, under their service contracts, the action that providers will take to ensure compliance with the Portfolio of Indicators for Eye Health and Care follow-up performance standard. Where …
Safety Recommendation
Lack of timely monitoring of patients with glaucoma
It is recommended that the Royal College of Ophthalmologists agree criteria for the risk stratification of patients with glaucoma so that practice can be standardised across NHS hospital eye services.
Safety Recommendation
Lack of timely monitoring of patients with glaucoma
It is recommended that the Royal College of Ophthalmologists, working with relevant stakeholders, develop models and review workforce required for the optimal delivery of glaucoma care. The models should be tested and evaluated. It is recommended that the Royal College …
Safety Recommendation
NCEPOD recommendations(68)— showing 50 strongest matches
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
CQC inspection actions(972)— showing 50 strongest matches
Royal Victoria Infirmary
The service must ensure robust governance processes are in place to lead, manage, risk assess and sustain effective services.
Must Do
Nottingham City Hospital
The trust must ensure there is an effective risk and governance system in place that supports safe quality care for all areas in the service, mitigates risks when identified, and is in line with the conditions placed upon their registration.
Must Do
Nottingham City Hospital
The trust must ensure there is an effective risk and governance system in place that supports safe quality care for all areas in the service, mitigates risks when identified, and is in line with the conditions placed upon their registration.
Must Do
Wythenshawe Hospital
The service should ensure premises and equipment are kept clean and in good repair to prevent, detect and control the spread of infection. This includes but is not limited regular cleaning of birthing pools in the birth centre.
Should Do
Wythenshawe Hospital
The service must assess, monitor and improve the quality and safety of the services provided in a timely way. Regulation 17(2)(a)
Must Do
Wythenshawe Hospital
The service must ensure there are sufficient quantities of appropriate equipment, including fetal and maternal monitoring equipment and bilirubinometers, to ensure the safety of women, birthing people and babies. Regulation 12(1)(2)(f)
Must Do
Worthing Hospital
The trust must review its existing IPC audit monitoring systems to identify any shortfalls in infection prevention and control so action can be taken to make improvements when needed.
Must Do
Worthing Hospital
The trust must ensure the Patient Group Directive treatment of neutropenic patients is reviewed in a timely manner.
Must Do
William Harvey Hospital
The trust should ensure Allied Health Professionals have access to enough space in the hospital to conduct patient assessments.
Should Do
William Harvey Hospital
The trust must ensure staff follow infection control principles, including the use of Personal Protective Equipment.
Must Do
William Harvey Hospital
The trust must ensure the risks associated with reported safety concerns are mitigated promptly.
Must Do
West Suffolk Hospital
The service must ensure governance arrangements establish timely compliance with national recommendations and ensure oversight of local audits.
Must Do
Weston General Hospital
Ensure the emergency department risk register is regularly reviewed and maintained to ensure that it is an effective tool to manage risks and provide assurance that controls are effective.
Must Do
Weston General Hospital
Continue to develop governance systems and processes and review their effectiveness.
Must Do
Westmorland General Hospital
The service should ensure staff clean the birthing pool in line with the policy for cleaning of the birthing pool, which should be reviewed, ratified and implemented to control the risk of spread of infection.
Should Do
Westmorland General Hospital
The service should ensure the policy for cleaning of the birthing pool is ratified and implemented to control the risk of spread of infection.
Should Do
Westmorland General Hospital
The trust should ensure that systems and processes are established and operated effectively to identify, assess, monitor, escalate and take mitigating actions, particularly in relation to the safest storage of medicine and the checking of emergency resuscitation equipment.
Should Do
Westmorland General Hospital
The service should ensure the policy for cleaning of the birthing pool is ratified and implemented to control the risk of spread of infection.
Should Do
Westmorland General Hospital
The trust should ensure that Patient Group Directions oversight should be strengthened to ensure sure appropriate and timely review and implementation.
Should Do
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Must Do
Westmorland General Hospital
The service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Must Do
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Must Do
Westmorland General Hospital
The service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Must Do
Westmorland General Hospital
The trust must implement an effective risk and governance system for the whole stroke pathway.
Must Do
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Must Do
Westmorland General Hospital
The service must continue to develop a vision and strategy through engagement with staff, focused on sustainability and aligned to local plans within the wider health economy.
Must Do
Westmorland General Hospital
The trust must implement an effective risk and governance system for the whole stroke pathway.
Must Do
Westmorland General Hospital
The department must ensure that all known risks are singularly identified on the risk register and that risks are supported by robust action plans that can reduce or mitigate the risks. They must also ensure that these action plans are …
Must Do
Westmorland General Hospital
The service must ensure that audit information (including national audits) is submitted, up to date, accurate and properly analysed and reviewed by people with the appropriate skills and competence to understand its significance. When required, results should be escalated, and …
Must Do
Westmorland General Hospital
The trust must ensure that incidents are identified, graded appropriately to reflect the level of harm and that they are acted upon and investigated in a timely way.
Must Do
Westmorland General Hospital
The trust must ensure that risks in the organisation are correctly identified and appropriate mitigations put in place in a timely way
Must Do
Westmorland General Hospital
The trust must ensure that governance processes are robust and effective
Must Do
West Cumberland Hospital
The service must ensure that the assessment of risk, preventing, detecting, and controlling the spread of, infections, including those that are healthcare associated is managed in line with national guidance. This includes, but is not limited to, cleaning substances subject …
Must Do
University Hospital of Hartlepool
The service should create and monitor action plans with clear actions, timescales and action owners.
Should Do
University Hospital of Hartlepool
The service must ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services in respect of restrictive practices.
Must Do
University College Hospital & Elizabeth Garrett Anderson Wing
The service should ensure that daily checks are completed, recorded and are effective for all emergency trollies.
Should Do
University College Hospital & Elizabeth Garrett Anderson Wing
The service should continue to audit compliance and implement associated actions in relation to the ‘fresheyes’ intervention when reviewing fetal wellbeing in labour, to improve overall compliance and reduce risks to women and birthing people.
Should Do
The York Hospital
The trust should ensure that safety huddle documentation is formalised across the service.
Should Do
The York Hospital
The service should ensure they can evidence the decision making and governance processes surrounding the use of balloon catheters.
Should Do
The York Hospital
The trust should consider introducing pain audits to gain assurance that pain services are improving patients' outcomes.
Should Do
The York Hospital
The service should ensure they can evidence the decision making and governance processes surrounding the use of balloon catheters.
Should Do
The York Hospital
The service must implement a robust governance process and risk management strategy. They must ensure they have effective risk management processes in place to manage and mitigate all risks.
Must Do
The York Hospital
The service must implement an effective system to assess, monitor, and drive improvement in the quality and safety of the services provided. They must demonstrate improvements in patient outcomes to be in line with national guidance and benchmark against a …
Must Do
The York Hospital
The service must ensure clean utility doors are not left open or unlocked and accessible to patients or members of the public.
Must Do
The York Hospital
The service must implement a robust governance process and risk management strategy. For example, they must ensure they instigate a process to effectively triage women in a safe environment. They must ensure they have effective risk management processes in place …
Must Do
The York Hospital
The service must ensure they assess the risks during the triage process to ensure the health and safety of service users.
Must Do
The York Hospital
The trust must ensure they are delivering fundamental standards of care and patients receives safe and effective care that meets their needs.
Must Do
The York Hospital
The trust must ensure ongoing patient safety concerns such as falls, pressure ulcers and healthcare care acquired infections are addressed in a timely way and all possible actions are taken to address concerns.
Must Do
The York Hospital
The trust must ensure there is full clinical engagement to support operational performance and that challenges are resolved with a focus upon patient safety across the organisation.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure there are effective governance systems and processes to identify and manage incidents, risks, issues and performance and to monitor progress through completion of audits, action plans and oversight of improvements and reduce the recurrence of incidents …
Must Do
PHSO ombudsman recommendations(7)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Broken trust: making patient safety more than just a promise
The Government should seek cross-party support for embedding patient safety and the culture and leadership needed to support it as a long-term priority.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commit to funding further independent advocacy to support harmed patients, families and carers when they raise concerns or seek answers after an incident.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care and NHS England should further scrutinise the lack of compliance with duty of candour. They should review the operation of duty of candour to assess its effectiveness and make recommendations for improvement.
IMB individual recommendations(13)
Springhill (2023)
Monitoring any new initiatives rolled out to enable the prison to better scrutinise the impact and quality of healthcare delivery and the health complaints system (6.1.3, 6.1.4 and 6.1.10).
Governor / Director
Wormwood Scrubs (2020)
Given the Board’s concerns relating to the provision of healthcare services, will the Governor ensure: (i) regular meetings of the strategic healthcare partnership? (ii) a fit-for-purpose healthcare complaints system, delivering timely and appropriate responses, with agreed deadlines? (iii) a significant reduction in the number of cancelled hospital appointments?
Governor / Director
Peterborough (Women) (2022)
Because of the widespread perception among prisoners that all Healthcare services (Clinical, Mental, and substance misuse) are not up to the standard expected, going forward the prison should prioritise the review and monitoring of Complaints to Healthcare e.g. in the Monthly Clinical Governance Meeting, to ensure that standards are maintained and improved.
Governor / Director
Gartree (2023)
Can the Prison Service confirm to the Board who has overall responsibility for the health and wellbeing of prisoners at Gartree?
HMPPS
Pentonville (2020)
Will you commit to giving Pentonville the funding it needs to install CCTV on those wings which still do not have it?
Other
In Progress
Long Lartin (2020)
It is disappointing to report that measured safety, both for prisoners and staff, for the first eight months of the reporting year at the prison was poor.
Governor / Director
In Progress
Hindley (2020)
Would the Prison Service support prioritising further improvements for the safety of prisoners at Hindley?
HMPPS
Implemented
Stafford (2021)
Will HMPPS ensure that HMP Stafford and Practice Plus Group initiate, with immediate effect, a medicines management system that, unlike now, does not impair the safety of its residents and is put under close supervision until ALL previous recommendations (PPO, CQC, HMIP, etc.) have been fully and successfully delivered?
HMPPS
In Progress
Lowdham Grange (2021)
Ensure that the best outcomes for prisoners (safety, fair and humane treatment, health and wellbeing, progression and release) are achieved in the new arrangements for operating the contract for HMP Lowdham Grange from February 2023.
HMPPS
In Progress
Gartree (2021)
Can the Prison Service confirm to the Board who has overall responsibility for the health and wellbeing of the prisoners at Gartree?
HMPPS
Winchester (2022)
Would the minister agree that safety at Winchester is unsatisfactory and explain what other steps will be taken to ensure the recent positive trend is maintained?
Other
In Progress
Swansea (2025)
How will the Governor ensure that the IMB has consistent access to meeting agendas and minutes from the health partnership forum?
Governor / Director
Littlehey (2024)
this should be subject to continual monitoring by the Governor.
Governor / Director
In Progress
National patient safety alerts(2)
Health investigations(395)
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.7
The Independent Investigation Team is of the view that an audit should be undertaken to review the effectiveness of the introduction of the Standards and specifically to ensure that cases are now being referred to MDT Meetings, in accordance with the terms of the Standards.
east_of_england
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.6
The Clinical Standards introduced by the EIP Service constitute a positive step forward in terms of improving its own control structure and processes. The EIP Service should consider the introduction of ‘Practice Guidance Notes’, setting out what is required by each element of the Standards to ensure consistency of implementation …
east_of_england
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.2
Patient safety was compromised in this case by a failure to adopt a structured approach towards diagnosis. This could have been mitigated by a robust supervision process or equally by discussion in a MDT meeting. The EIP Service has strengthened its supervision and MDT processes since this incident and has …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
External, peer group audit should be incorporated into the Trust's quality assurance programme; and the Purchasers, perhaps in concert with the Department of Health, should develop contract monitoring measures more finely tuned to the needs of services for people with mental health problems.
east_of_england
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 34
DPT will audit understanding of and adherence to operational policies and care pathways.
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 30
DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are …
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 27
DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are …
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 23
DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are …
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 22
DPT will incorporate the key questions identified from the audit of clinical risk assessment into the Clinical Record Self Monitoring Process. This will improve the monitoring and performance management of this key area of practice by providing information which is then routinely considered at service and team level. This should …
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 20
DPT will develop and implement an audit mechanism to specifically monitor practice and adherence to NICE Clinical Guideline 45 – Antenatal and Postnatal Mental Health, to ensure multiagency information sharing, review, care and contingency planning is in place for all those in contact with secondary mental health services who are …
south_west
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 8
Tees, Esk and Wear Valley NHS Foundation Trust should review their governance systems to ensure they can demonstrate continuous and systematic monitoring of compliance and where necessary corrective action, to the Clinical Risk Policy by practitioners.
north_east_yorkshire
Independent investigation: John Stevens, Woking (2001) — Rec 18
We recommend that North West Surrey Mental Health Partnership Trust reviews the serious incident policy to a) Include the attendance of the oncall senior manager at the scene of the incident as soon as possible to take immediate action in supporting staff and patients and securing the notes to make …
south_east
Independent investigation: Eileen Cameron, Reading, Berks (1997) — Rec 12
that a senior manager within the trust is made responsible for ensuring that these Health Service Guidelines are put into practice.
south_east
Independent investigation: Edna Gadsby, Liverpool (2010) — Rec 6
The Governance arrangements integral to the Scott Clinic need to be reviewed, strengthened and aligned with the corporate processes and system adopted by all services in Mersey Care NHS Trust. The review should ensure that all the safety regulations are being met as part of the registration requirements of the …
north_west
Independent investigation: Denise Eckersley, Leeds (1999) — Rec 13
Further consideration should be given by the Department of Health to the issue, whether inquiries under HSC(94)27 should now be ended, with responsibility transferred to the National Patients Safety Agency, as outlined by the Minister in July 2001. Until the situation is resolved, the present inquiry system can be perceived …
north_east_yorkshire
Independent investigation: Denise Eckersley, Leeds (1999) — Rec 9
The Trust should ensure that, in an internal review in a case of homicide or another event of similar significance, there is some external representation on the Panel of Inquiry.
north_east_yorkshire
Independent investigation: Denise Eckersley, Leeds (1999) — Rec 8
The Trust should ensure that it continues to address the issue, that the investigation of a serious untoward incident should involve various individuals and should not devolve unduly into the hands of one director.
north_east_yorkshire
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R28
We recommend to SHAs that consideration should be given to ways of encouraging smaller independent hospitals, which have only limited infrastructure for the implementation of clinical governance, to look at partnership working with other providers or to join appropriate networks to access expertise and peer support.
south_east
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R15
We recommend to PCTs and Trusts that, when commissioning mental health services, whether from within the NHS or from the independent sector, evidence should be sought and obtained from service providers that they have incorporated the guidance from the Department of Health’s “Best Practice in Managing Risk” publication2 into their …
south_east
Independent investigation: Angela Titley, Private Psych hospital, Redhill, Surrey (2004) — Rec R1
We recommend that Whitepost Healthcare Group now commissions an independent, top to bottom, governance review at Shrewsbury Court with the objective of consolidating and building upon on the improvements made there since the homicide and supplementing the Recommendations and Requirements provided to date by the HC.
south_east
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 40
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on leave from in-patient units are subject to appropriate security arrangements, and that these arrangements are regularly reviewed and updated.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 38
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all in-patient units have appropriate security arrangements in place, and that these arrangements are regularly reviewed and updated.
midlands
Independent investigation: Vincent Douglas, Lewisham (2017) — Rec 1
Our team recommends that a Non-Executive Director be nominated to carry specific responsibility at Trust Board level to support dissemination of learning from incidents.
london
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 34
We recommend that the AWOL policy should be put into effect immediately when a patient is noticed to be missing. The policy, however, needs to cater for the circumstances where a patient, either voluntary or detained under the Mental Health Order, has been located and is known to be safe. …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 27
We recommend that the policies (and procedures) on Observations and Leave should be explicitly cross-referenced.
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 21
We recommend that the Observations policy should explicitly refer to the ‘Assessment and Management of Risk’ policy as one that is linked to it. There is also an obvious link to the Admissions and Discharge policy and this should be recorded too. In all cases, we believe that the initial …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 12
We recommend that the Trust’s response to homicides should be included in revised policies and procedures on Serious Untoward Incidents, rather than forming a stand-alone policy.
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 11
Other policies that we have considered differentiate between, and provide definitions of, untoward incidents and serious untoward incidents. They provide categories of incidents, with each category requiring a different response for which clear instructions are given. There is also a clear indication of staff responsibilities, including the reporting of each …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 10
We recommend that the Trust (and others delivering similar services) should seek the assistance of the National Patient Safety Agency (NPSA) to train staff in the techniques of Root Cause Analysis (RCA), and that they should then develop policies and guidance on how untoward incidents are to be managed. We …
northern_ireland
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 18
Hertfordshire Partnership NHS Foundation Trust should conduct an audit of compliance with the checklist outlined in the Learning Note issued to CATT and Liaison Team staff in February 2012.
east_of_england
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 14
West Hertfordshire Hospitals NHS trust should ensure that responses to reports from the Coroner are accurate and that procedures are in place to make sure that Rule 43 reports are identified and that information is collected and action considered within a governance process which is monitored by the trust board.
east_of_england
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 13
West Hertfordshire Hospitals NHS Trust should ensure that the services it provides to those with a diagnosis of epilepsy follow NICE guidance. In particular: “Review and referral: At the review children, young people and adults should have access to: written and visual information, counseling service, information about voluntary organisations, epilepsy …
east_of_england
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 4
Hertfordshire Partnership NHS Foundation Trust should ensure that the ongoing implementation of the operational policies detailing roles, responsibilities, work methods, processes, assessment methodologies and tools and interface arrangements in place for both the CATT and psychiatric liaison service are monitored, and there is demonstrable evidence in place to ensure that …
east_of_england
Independent investigation: Ryan Merna, Poole — Rec 3
The NHS Dorset Clinical Commissioning Group must ensure that: • provider action plans properly address recommendations in the associated serious incident reports; • provider action plans are appropriately monitored, and that evidence is assessed to provide assurance that the required actions are in place; • when actions are not completed …
south_west
Independent investigation: Ryan Merna, Poole — Rec 2
The NHS Dorset Clinical Commissioning Group must ensure that provider serious incident reports comply with all of the standards set out in the NHS England Serious Incident Framework, that there is an audit trail of assessment of serious incident reports, and that appropriate action is taken when this is not …
south_west
Independent investigation: Ryan Merna, Poole — Rec 1
The Trust must ensure that all serious incident reports comply with all of the standards set out in the NHS England Serious Incident Framework so that: • root causes to incidents are clear in cases where they are identified; • appropriate learning can be identified and shared; • findings can …
south_west
Independent investigation: Rodney Wells, Nottingham (2006) — Rec R4
When the trust’s serious untoward incident policy is next reviewed, the trust should take the opportunity to include reference to the need for members of internal investigation teams to be independent of the service and/or geographical area within which the incident occurred.
midlands
Independent investigation: Michael Green, Nottingham (2005) — Rec R2
The trust should continue to audit compliance with its observation policy and provide evidence of the audit outcomes to its lead commissioners Nottingham City PCT.
midlands
Independent investigation: Michael Galloway, Illingworth (1999) — Rec 6.6
The panel recommends that the Trust should review its position with regard to clinical supervision and monitor compliance with its policies and systems.
north_east_yorkshire
Independent investigation: Michael Galloway, Illingworth (1999) — Rec 6.2
The panel recommends that, in conjunction with the commissioners of the service, the Trust with operational responsibility for the in-patient ward should review the appropriateness of the patient mix being cared for on the ward.
north_east_yorkshire
Independent investigation: Martin Ellicot, Walthamstow (2006) — Rec 3
Trust Boards should take the lead in ensuring that procedures, management and governance arrangements are clear, effective and well resourced.
london
Independent investigation: Marta Elena Vento, Bournemouth (2020) — Rec R16
NHS England’s Health and Justice team need to gain robust assurance from the healthcare service in the prison that it has the governance, performance systems and processes in place to ensure it is delivering high quality and safe care.
south_west
Independent investigation: Lesley Wright, Tooting (2006) — Rec R11
The trust should ensure that team managers implement the CPA policy and procedures, that all CMHT staff have training and refresher training in the operation of the CPA and that risk assessments are completed as part of the CPA process. The trust should undertake frequent audits to ensure compliance with …
london
Independent investigation: Lesley Wright, Tooting (2006) — Rec R5
The trust should ensure that managers regularly audit records of team meetings to assess their quality and compliance with trust standards.
london
Independent investigation: Lee Johnson, Newcastle (2003) — Rec 10
The procedure to appoint the inquiry panel should be commenced within four months of the conclusion of any criminal proceedings save in exceptional circumstances.
north_east_yorkshire
Independent investigation: Leanne Unsworth, Burnley (2019) — Rec 5
The Trust should ensure that its internal serious incident investigation processes are robust, timely and compliant with national guidance. This should include multidisciplinary investigation teams, clear terms of reference, comprehensive archives, and effective feedback mechanisms to treating teams and families/carers.
north_west
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 33
Steps should be taken by the DHSSPS, in conjunction with Boards, Trusts and other relevant bodies such as the Mental Health Commission and ACPCs, to draw up and issue guidance regarding the production of initial investigation reports by Trusts, in situations where there has been a serious incident such as …
northern_ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 26
Both South and East Belfast and Foyle Trusts should have in place as part of their governance arrangements a system to monitor and audit case records within Mental Health services to ensure: - Accuracy - Assessment and management of risk - Care planning - Effectiveness of treatment - Discharge planning …
northern_ireland
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 25
Boards and Trusts must ensure that each in-patient unit has a bed management policy in place, which outlines the bed management system and identifies an accountable named individual.
northern_ireland
Independent investigation: Kasey Gordon, Tottenham (2011) — Rec 2
The Trust to ensure that the action plan continues to be monitored and its progress reported upwards via its governance reporting systems.
london
Article 2 learning points(5)
— LP 6
We recommend that this should be a stipulation in the membership of all case review panels and that the Governor should establish that this is now observed at HMP Swansea.
HMPPS
Accepted
— LP 3
We recommend that the Governor of HMP Swansea is asked to establish that appropriate arrangements are in place.
HMPPS
Accepted
— LP 1
We recommend that the Governor of HMP Swansea is asked to establish that robust measures are now in place to ensure that these breaches no longer happen.
HMPPS
Accepted
— LP 2
I recommend that NHS England and NOMS: take note of the findings in Chapter 11, and consider jointly in the light of this investigation whether the lessons of this investigation have a wider application; in particular, that they consider whether they are satisfied that adequate arrangements are now in place …
NHS England, NOMS
— LP 1
I recommend that, those responsible for healthcare governance at HMP Lincoln and HMP Ranby: identify the requirements of good practice in the specific areas identified below, in the light of the problems that occurred in this case and taking account of NHS and NOMS policies; review their current arrangements and …
HMP Lincoln, HMP Ranby
Independent reviews(50)
Ockenden Review — Rec LAfL 14.6
Improving Management of Patient Safety Incidents All SIs must be completed within the timeframe set out in the SI framework. Any SIs not meeting this timeline should be escalated to the Trust Board.
Health & Social Care
Ockenden Review — Rec LAfL 14.5
Improving Management of Patient Safety Incidents Individuals clinically involved in an incident should input into the evidence gathering stage, but never form part of the team that investigates the incident.
Health & Social Care
Ockenden Review — Rec LAfL 14.4
Improving Management of Patient Safety Incidents The use of HRCRs to investigate incidents must be abolished and correct processes, procedures and terminology must be used in line with the relevant Serious Incident Framework.
Health & Social Care
Ockenden Review — Rec LAfL 14.3
Improving Management of Patient Safety Incidents All investigations must be undertaken by a multi-professional team of investigators and never by one individual or a single profession.
Health & Social Care
Ockenden Review — Rec LAfL 14.1
Improving Management of Patient Safety Incidents Incidents must be graded appropriately, with the level of harm recorded as the level of harm the patient actually suffered and in line with the relevant incident framework.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 18
Safety systems should routinely collect information on staff group to facilitate monitoring and interrogation at a national level, against agreed patient safety standards, to determine any system-level issues in multidisciplinary team working.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 13
There should be an ongoing national audit of safety outcomes in anaesthesia practice in conjunction with the Healthcare Quality Improvement Partnership to provide assurance of the safety of the physician assistants in anaesthesia role, in teams with and without physician assistants in anaesthesia.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 12
Any further expansion in the deployment of physician assistants in anaesthesia should be taken forward in conjunction with the Royal College of Anaesthetists to build safe and effective models of anaesthesia delivery that are supported by the consultant community.
Health & Social Care
Carter NHS Productivity Review — Rec 8
NHS Improvement and NHS England should establish joint clinical governance by April 2016 to set standards of best practice for all specialties, which will analyse and produce assessments of clinical variation, so that unwarranted variation is reduced, quality outcomes improve, the performance of specialist medical teams is assessed according to …
Health & Social Care
Shelley NHS Hospital Food Review — Rec 8
Going forward: a) Set up an expert group of hospital caterers, dietitians and nurses, with input from infection prevention and control, and sustainability and staff health and well-being leads, to oversee hospital performance and progress against these recommendations, with suitable terms of reference. b) The expert group to maintain momentum …
Health & Social Care
Shelley NHS Hospital Food Review — Rec 3
Food safety: a) There must be open and speedy communication channels for food safety concerns between auditors, local authorities, PHE, FSA, suppliers and trusts, with appropriate governance structures to ensure concerns are acted upon swiftly. b) Every trust must have a nominated food safety specialist and a named board member …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 24
Assessment of systems for reporting adverse events should be part of CQC's registration and assessment of providers. Adverse incident reporting should be a standard component of professional appraisals and revalidation.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 22
The Director of Patient Safety for NHS England should develop a framework to encourage and support the reporting of suspected device failures to the MHRA.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 14
Those training to be non surgical practitioners should have a clear understanding of the requirement to operate from a safe premises, and the responsibilities involved. The training curriculum should include topics such as infection control, treatment room safety and adverse incident reporting. The code of conduct for those on the …
Health & Social Care
Francis Inquiry (Mid Staffs 2010) — Rec 18
All NHS trusts and foundation trusts responsible for the provisions of hospital services should review their standards, governance and performance in the light of this report.
Health & Social Care
Francis Inquiry (Mid Staffs 2010) — Rec 14
The Trust should ensure that its nurses work to a published set of principles, focusing on safe patient care.
Health & Social Care
Francis Inquiry (Mid Staffs 2010) — Rec 7
Trust policies, procedures and practice regarding professional oversight and discipline should be reviewed in the light of the principles described in this report.
Health & Social Care
Paterson Inquiry — Rec 12
We recommend that if, when a hospital investigates a healthcare professional's behaviour, including the use of an HR process, any perceived risk to patient safety should result in the suspension of that healthcare professional. If the healthcare professional also works at another provider, any concerns about them should be communicated …
Health & Social Care
Paterson Inquiry — Rec 11
We recommend that the Government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry.
Health & Social Care
Paterson Inquiry — Rec 9
We recommend that a national framework or protocol, with guidance, is developed about how recall of patients should be managed and communicated. This framework or protocol should specify that the process is centred around the patient's needs, provide advice on how recall decisions are made, and advise what resource is …
Health & Social Care
Paterson Inquiry — Rec 8
We recommend that Spire should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen, and that they should check that they have been given an ongoing treatment plan in the same way that has been provided for patients in the …
Health & Social Care
Paterson Inquiry — Rec 7
We recommend that the University Hospitals Birmingham NHS Foundation Trust board should check that all patients of Paterson have been recalled, and to communicate with any who have not been seen.
Health & Social Care
Paterson Inquiry — Rec 5
We recommend that CQC, as a matter of urgency, should assure itself that all hospital providers are complying effectively with up-to-date national guidance on MDT meetings, including in breast cancer care, and that patients are not at risk of harm due to non-compliance in this area.
Health & Social Care
Paterson Inquiry — Rec 1
We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data, for example, how many times a consultant has performed a particular procedure and how recently. This should be accessible and understandable to …
Health & Social Care
Berwick Review — Rec 2
All leaders concerned with NHS healthcare – political, regulatory, governance, executive, clinical and advocacy – should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement and support.
Health & Social Care
Morecambe Bay Investigation — Rec 41
We were concerned by the ad hoc nature and variable quality of the numerous external reviews of services that were carried out at the University Hospitals of Morecambe Bay NHS Foundation Trust. We recommend that systematic guidance be drawn up setting out an appropriate framework for external reviews and professional …
Health & Social Care
Morecambe Bay Investigation — Rec 39
There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith in her review of the Shipman deaths, but is in …
Health & Social Care
Morecambe Bay Investigation — Rec 37
Organisational change that alters or transfers responsibilities and accountability carries significant risk, which can be mitigated only if well managed. We recommend that an explicit protocol be drawn up setting out how such processes will be managed in future. This must include systems to secure retention of both electronic and …
Health & Social Care
Morecambe Bay Investigation — Rec 36
The cumulative impact of new policies and processes, particularly the perceived pressure to achieve Foundation Trust status, together with organisational reconfiguration, placed significant pressure on the management capacity of the University Hospitals of Morecambe Bay NHS Foundation Trust to deliver against changing requirements whilst maintaining day-to-day needs, including safeguarding patient …
Health & Social Care
Morecambe Bay Investigation — Rec 32
The Local Supervising Authority system for midwives was ineffectual at detecting manifest problems at the University Hospitals of Morecambe Bay NHS Foundation Trust, not only in individual failures of care but also with the systems to investigate them. As with complaints, our remit was not to examine the operation of …
Health & Social Care
Morecambe Bay Investigation — Rec 27
Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do so. Failure to report concerns should be regarded as a lapse from professional standards. Action: the General Medical Council, the …
Health & Social Care
Morecambe Bay Investigation — Rec 25
We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external bodies such as the Care Quality Commission and Monitor. The …
Health & Social Care
Morecambe Bay Investigation — Rec 23
Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there is a strong case to include a requirement that investigation …
Health & Social Care
Morecambe Bay Investigation — Rec 15
The University Hospitals of Morecambe Bay NHS Foundation Trust should continue to prioritise the work commenced in response to the review of governance systems already carried out, including clinical governance, so that the Board has adequate assurance of the quality of care provided by the Trust's services. This work is …
Health & Social Care
Morecambe Bay Investigation — Rec 12
The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements for additional training. The Trust should ensure that robust documentation …
Health & Social Care
Morecambe Bay Investigation — Rec 6
The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who will carry out this assessment against which criteria; and how …
Health & Social Care
Cumberlege Review — Rec 8
Transparency of payments made to clinicians needs to improve. The register of the General Medical Council (GMC) should be expanded to include a list of financial and non-pecuniary interests for all doctors, as well as doctors' particular clinical interests and their recognised and accredited specialisms. In addition, there should be …
Health & Social Care
Cumberlege Review — Rec 6
The Medicines and Healthcare products Regulatory Agency (MHRA) needs substantial revision particularly in relation to adverse event reporting and medical device regulation. It needs to ensure that it engages more with patients and their outcomes. It needs to raise awareness of its public protection roles and to ensure that patients …
Health & Social Care
Darzi Review — Rec 12
The picture on quality of care is mixed. For the most part, once people are in the system, they receive high quality care. But there are some important areas of concerns, such as maternity care, where there have been a succession of scandals and inquiries. There have been improvements in …
Health & Social Care
Cass Review — Rec 32
Wider guidance applicable to all NHS services should be developed to support providers and commissioners to ensure that innovation is encouraged but that there is appropriate scrutiny and clinical governance to avoid incremental creep of practice in the absence of evidence.
Health & Social Care
Accepted
Cass Review — Rec 1
Given the complexity of this population, these services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors. There should be a nominated medical practitioner (paediatrician/child psychiatrist) who takes overall clinical responsibility for patient safety within the service.
Health & Social Care
Accepted
Ockenden Review — Rec LAfL 14.18
Improving Audit Process There must be midwifery and obstetric co-leads for audits.
Health & Social Care
Ockenden Review — Rec LAfL 14.16
Improving Complaints Handling Complaints themes and trends should be monitored at the maternity governance meeting, with actions to follow and shared with the MVP.
Health & Social Care
Ockenden Review — Rec LAfL 14.7
Improving Management of Patient Safety Incidents All members of the governance team who lead on incident investigations should attend regular appropriate training courses not less than three yearly. This should be included in local governance policy. These training courses must commence within the next 12 months
Health & Social Care
Ockenden Review — Rec LAfL 14.2
Improving Management of Patient Safety Incidents The Trust executive team must ensure an appropriate level of dedicated time and resources are allocated within job plans for midwives, obstetricians, neonatologists and anaesthetists to undertake incident investigations.
Health & Social Care
Review of patient safety across the health and care landscape — Rec 3
Most investigations into safety incidents should continue to be managed within provider organisations and commissioners ( ICBs ), with support from regions where required, to ensure they are: HSSIB should operate as a dedicated, expertise-led investigation facility that can be used in a responsive way to minimise the number of …
Health & Social Care
Review of patient safety across the health and care landscape — Rec 1
A revamped, revitalised and reinforced NQB should be responsible for developing a comprehensive strategy to improve quality of care that is in line with the aims of DHSC and the NHS in England. This strategy should build on: This strategic approach should: More specifically, NQB should set out a vision …
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 14
A permanent faculty should be established to provide professional leadership and set postgraduate standards for physician assistants in anaesthesia, under the auspices of the Royal College of Anaesthetists ( RCoA ).
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 8
A permanent faculty should be established to provide professional leadership for physician assistants, with standards for training and credentialling set by relevant medical royal colleges or the Academy of Medical Royal Colleges.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 6
The physician assistant role should form part of a clear team structure, led by a senior clinician, where all are aware of their roles, responsibilities and accountability. A named doctor should take overall responsibility for each physician assistant as their formal line manager (‘named supervisor’).
Health & Social Care
PHSO casework decisions(20)
P-004714 — University Hospitals Birmingham NHS Foundation Trust
Mr A complained his father was sexually assaulted by another patient, alleging the Trust knew of the risk but failed to safeguard and later provided false information in its response.
NHS in England
Jan 2026
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-003414 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs A complained the Trust failed to properly support and monitor her brother during a Trial Without Catheter (TWOC), and staff delayed acting on dangerous symptoms, leading to his death.
NHS in England
Mar 2025
P-004314 — Lancashire Teaching Hospitals NHS Foundation Trust
Complaint alleged significant delays in her husband's hospital admission, inadequate communication, delayed consultant review, and a postponed transfer for heart surgery, leading to his death.
NHS in England
Upheld
Nov 2025
P-004424 — Barts Health NHS Trust
Her father was assaulted in the Emergency Department due to the Trust's failure to assess and manage a high-risk patient, causing significant injuries and family trauma.
NHS in England
Nov 2025
P-001449 — Wye Valley NHS Trust
Ms A complained about a doctor’s conduct, the Trust's failure to treat her knee pain, and refusal of an arthroscopy, resulting in job loss and distress.
NHS in England
Jul 2022
P-001587 — Stockport NHS Foundation Trust
Mrs A complained her kidney stent replacement surgery was incorrectly performed, causing physical pain, emotional distress, and a loss of trust in the Trust.
NHS in England
Aug 2022
P-001488 — University Hospitals Bristol and Weston NHS Foundation Trust
Mr O complained about a consultant cardiologist's traumatic and distressing attitude during his inpatient stay, causing immense stress, anxiety, and fear of hospitals.
NHS in England
Aug 2022
P-001539 — North Bristol NHS Trust
Ms A complained about a lack of breast cancer nurse support, delayed treatment, inadequate surgical discussions, incorrect reconstructive surgery, and poor complaint handling.
NHS in England
Sep 2022
P-003305 — Manchester University NHS Foundation Trust
Mrs E complained staff allowed her husband to fall by letting him go to the bathroom alone, leading to his death. She also alleged poor communication about his fall and deterioration.
NHS in England
Jan 2025
P-003348 — Kettering General Hospital NHS Foundation Trust
Miss G complained her premature son suffered a deep tissue burn from a monitor, alleging staff negligence, failure to inform her, escalate the injury, conduct skin checks, or follow policies.
NHS in England
Feb 2025
P-004130 — A practice in the Oldham area
Mrs B complained the Trust failed to protect her sister from infection during investigations while she was undergoing chemotherapy, contributing to her chest infection and death.
NHS in England
Partly Upheld
Oct 2025
P-004487 — University Hospitals Sussex NHS Foundation Trust
Mr Y complained his mother was left unattended, leading to a fall and subsequent death. He also criticised the Trust's investigation for inconsistencies and downplaying the incident.
NHS in England
Dec 2025
P-001237 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mrs O complained she fell as an inpatient, sustaining a fractured spine that left her unable to walk and requiring care home placement.
NHS in England
Dec 2021
P-001957 — Croydon Health Services NHS Trust
Mr G complained the Trust's decision to stop his sister's antibiotics despite working blood results caused her death, questioning the ethical and legal basis of the decision.
NHS in England
Apr 2023
P-003854 — A dental practice in the Bromley area
Mr E complained a hygienist appointment led to a cracked wisdom tooth, the Practice gave incorrect information about removal, and caused facial nerve damage during the extraction.
NHS in England
Jul 2023
P-003899 — A dental practice in the Lambeth area
Mr I complained a dental practice removed a tooth without good reason and failed to provide a replacement dental bridge. This allegedly caused chewing issues, and he sought financial compensation for replacement.
NHS in England
Aug 2023
P-002833 — Homerton Healthcare NHS Foundation Trust
Ms E complained her surgeon and anaesthetist inadequately explained spinal anaesthesia, the surgery on her leg was incorrect, and she struggled to access aftercare and rehabilitation, causing significant distress.
NHS in England
Aug 2024
P-002940 — Barts Health NHS Trust
Mr H complained trainee surgeons incorrectly performed his tonsillectomy, only partially removing his tonsils, causing him pain, discomfort, a lisp, and requiring a further operation.
NHS in England
Sep 2024
P-004367 — Sandwell and West Birmingham Hospitals NHS Trust
Mrs D complained about poor care during childbirth, including struggling with forceps, improper episiotomy stitching, and delayed cleaning/dressing of her daughter's facial wound, causing permanent scarring and distress.
NHS in England
Nov 2025
LGO / SPSO decisions(444)
NIPSO-18869 — Northern Health and Social Care Trust
An investigation by the Public Services Ombudsman has found that the Northern Health and Social Care Trust did not properly monitor a patient’s food and drink intake during her stay in the Antrim Area Hospital.
NIPSO (NI Public Service…
Health & Social Care
Jun 2020
NIPSO-19704 — South Eastern Health and Social Care Trust
The Ombudsman recommended that a patient be given an apology after an investigation found he did not receive the fundamental standards of care while being treated in hospital. Failures included the lack of records relating to the decision to admit him to an escalation bed, and a failure to record …
NIPSO (NI Public Service…
Health & Social Care
Jul 2020
NIPSO-17125 — Northern Health and Social Care Trust
The Ombudsman has made a recommendation to the Northern Health and Social Care Trust to reduce the risk of a delay in the communication of results to patients, and to patients receiving results in unplanned circumstances, following an investigation into the care of a man with terminal lung cancer.
NIPSO (NI Public Service…
Health & Social Care
Jul 2020
NIPSO-17919 — Homecare Independent Living
We recommended that a healthcare provider review its policies and improve staff training after we investigated the care it provided to a complainant’s elderly mother.
NIPSO (NI Public Service…
Health & Social Care
Oct 2020
NIPSO-16741 — Belfast Health and Social Care Trust
Our investigation into a complaint about the care and treatment of a cancer patient has led to an apology to the complainant and a review of the issue of pain management on two wards in the Mater and Royal Victoria hospitals.
NIPSO (NI Public Service…
Health & Social Care
Jan 2021
NIPSO-202001078 — Department of Health
We investigated a complaint from a member of the public who believed she was treated unfairly by the Department of Health.
NIPSO (NI Public Service…
Central Government
Upheld
Jun 2023
NIPSO-201912205 — Southern Health and Social Care Trust
We found failures in the care provided by the Southern Trust to an elderly woman and her daughter.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2023
NIPSO-202000522 — Belfast Health and Social Care Trust
A man whose son lived in supported housing complained about the care provided by the Belfast Trust. We upheld his complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2023
NIPSO-202002717 — Belfast Health and Social Care Trust
A woman complained about the care her elderly mother received over a 10 day period in the Mater Hospital. We upheld parts of the complaint, including over how the hospital dealt with an incident in which the patient was in an agitated state, and the way it managed her food …
NIPSO (NI Public Service…
Health & Social Care
Upheld
Dec 2023
NIPSO-care-and-treatment-patient-antrim-area-hospital-0 — Northern Health and Social Care Trust
A woman complained that the Northern Trust should have consulted her and her family when making decisions around the care of her late mother. We found the Trust's decision making at the time was appropriate, but were critical of the way it dealt with her complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
PSOW-202500244 — Aneurin Bevan University Health Board
Mr X complained that Aneurin Bevan University Health Board had failed to respond to his complaint. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr Xs complaint. She said this caused inconvenience and frustration for Mr X. The Ombudsman decided to …
PSOW (Public Services Om…
Health
May 2025
22-003-453b — Mersey Care NHS Foundation Trust (FT) (22 003 …
Summary: We found fault by a Council and ICB as they failed to provide Mrs R with care and support to meet her assessed needs. The Council and ICB will apologise to Mrs R’s son, Mr P, and pay him a financial remedy in recognition of the distress this caused …
LGO (Local Government & …
Health
Not Upheld
Dec 2022
22-017-440a — Royal United Hospitals Bath NHS Foundation Trust (22 …
Summary: We uphold Miss Y’s complaint about her father’s hospital discharge and care. We found fault with the way Mr X was discharged from hospital, the care he received in a care home and some aspects of his hospital inpatient care. As a result, Mr X did not receive the …
LGO (Local Government & …
Health
Upheld
May 2024
24-021-087a — South West London & St. Georges Mental Health …
Summary: Mr A has complained about a lack of aftercare planning by a Council, Integrated Care Board and a Mental Health Trust for his daughter, Miss B. Mr A said this led to deterioration in her mental health. We found fault with these organisations who have agreed to carry out …
LGO (Local Government & …
Health
Upheld
Nov 2025
NIPSO-18957 — Belfast Health and Social Care Trust
The patient complained that he should have had a scan and been assessed for surgery on his groin, about the attitude of the consultant who saw him, and that he was discharged from the hospital without any pain relief.
NIPSO (NI Public Service…
Health & Social Care
Jun 2020
NIPSO-16347 — Belfast Health and Social Care Trust
A complainant who believed that her mother was not fit to be discharged from hospital, and who said she should not have been sent home without medication, has had part of her complaint about the Belfast Health and Social Care Trust upheld.
NIPSO (NI Public Service…
Health & Social Care
Oct 2020
NIPSO-16347 — Belfast Health and Social Care Trust
We upheld parts of a complaint about the management of the patient's pain relief, the hospital's communication with her family, the supply of her medication, and the decision to discharge her.
NIPSO (NI Public Service…
Health & Social Care
Dec 2020
NIPSO-201915832 — Western Health and Social Care Trust
We found that the Trust failed to follow any multidisciplinary assessments when it assessed a patient for Continuing Healthcare.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-20700 — Belfast Health and Social Care Trust
We found that the Belfast Health and Social Care Trust did not provide a patient with a multi-disciplinary review prior to her discharge from the Royal Victoria Hospital.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-18735 — Belfast Health and Social Care Trust
We have asked the Belfast Health and Social Care Trust, in consultation with the other Trusts and health and social care organisations, to agree a uniform approach for assessing all future applications for Continuing Healthcare in Northern Ireland.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-19010 — South Eastern Health and Social Care Trust
We found that the South Eastern Health and Social Care Trust dealt with a complainant’s concerns fairly, but were critical of the time it took to address them.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
NIPSO-202000673 — Woodbrooke Medical Practice
Our investigation found that the GP Practice properly managed the patient’s medication, and that it made appropriate referrals for further testing.
NIPSO (NI Public Service…
Health & Social Care
Mar 2023
NIPSO-202000636 — Southern Health and Social Care Trust
We found that the care provided by Craigavon Area Hospital to a woman and her new born baby was appropriate, but upheld the complaint that they were discharged prematurely.
NIPSO (NI Public Service…
Health & Social Care
May 2023
NIPSO-202000037 — Southern Health and Social Care Trust
A man said that his partner could have avoided emergency surgery had she received better treatment from the Southern Health and Social Care Trust. We did not uphold the complaint.
NIPSO (NI Public Service…
Health & Social Care
May 2023
NIPSO-improving-healthcare-through-better-patient-engagement — Various
Shared decision making in a healthcare setting is about involving patients and their families in decisions about their clinical care. Not only does this foster a more compassionate, effective healthcare service, it is vital for patient safety. By listening to and working with patients, a service is more likely to …
NIPSO (NI Public Service…
Health & Social Care
Sep 2024
NIPSO-202003738 — Belfast Health and Social Care Trust
A woman complained about the care provided by the Belfast Health and Social Care Trust to her late father in his final weeks. We upheld parts of the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jan 2025
NIPSO-202002627 — Northern Health and Social Care Trust
The Northern Trust failed to act on a woman’s concerns about her mother’s health. This, as well as its failure to properly assess her spinal injury and accurately read the results of an MRI scan, led to her untimely death.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
NIPSO-202005529 — Northern Health and Social Care Trust
A woman complained that failures in her husband’s care while he was in hospital contributed to a deterioration in his health. We partially upheld the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
May 2025
NIPSO-202400522 — Northern Health and Social Care Trust
The Northern Trust failed to develop an appropriate plan for managing a patient’s incontinence during his stay in Causeway Hospital.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Oct 2025
PSOW-202005689 — Aneurin Bevan University Health Board
Mr X complained to the Ombudsman about the care that Aneurin Bevan University Health Board (the Health Board) had provided to his late son. Mr X had complained to the Health Board in May 2020 and received a response in October 2020. However, in making his complaint to the Ombudsman, …
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202005955 — Aneurin Bevan University Health Board
Mr X complained that the Health Board had not responded to his complaint about his late wife’s care and treatment made in May 2020. The assessment found that the response was outstanding. In order to resolve the complaint, the Health Board agreed to issue an appropriate response and it did …
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202005973 — A GP Practice in the area of Hywel …
Lack of GP complaint response
PSOW (Public Services Om…
Health
Apr 2021
PSOW-201907352 — Swansea Bay University Health Board
Ms A complained about the treatment and care received by her late uncle, Mr B, during his stay on Dan Danino Ward (the Ward) at Morriston Hospital (the First Hospital) between 6 March and 3 July 2019. In particular, she complained that Swansea Bay University Health Board (the Health Board) …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202000225 — Swansea Bay University Health Board
Mrs X complained that Swansea Bay University Health Board (the Health Board) failed to treat her mother (Mrs Y) in a timely manner and within the NHS Wales, Rules for Managing Referral to Treatment Waiting Times (RTT targets). Mrs Y had an endometrial carcinoma (a form of cancer affecting the …
PSOW (Public Services Om…
Health
Not Upheld
Apr 2021
PSOW-202001107 — Aneurin Bevan University Health Board
Mrs A complained about the treatment she received from Aneurin Bevan University Health Board between February 2019 and March 2020. Specifically, Mrs A complained that a specialist scan did not identify a tumour in her uterus. She was unhappy that treatment options, including a possible hysterectomy, were not fully considered …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202001144 — Cardiff and Vale University Health Board
Ms D complained about the treatment she received at the Emergency Department (the ED) of the University Hospital of Wales (the UHW) when clinicians misdiagnosed an injury that she sustained to her left ankle following a fall. Ms D complained that, after reviewing an X-ray, an Emergency Nurse Practitioner (an …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202001850 — A GP Practice in the area of Aneurin …
Mrs B complained about the care and treatment provided to her husband, Mr B, by a GP Practice in the area of the Aneurin Bevan University Health Board (the Practice). She complained that when her husband, Mr B, attended the Practice with symptoms and a family history of diabetes, the …
PSOW (Public Services Om…
Health
Upheld
Apr 2021
PSOW-202004183 — Aneurin Bevan University Health Board
Mrs A complained about the care given to her late mother, Mrs B, who developed urosepsis while under the care of Aneurin Bevan University Health Board (the Health Board). Whilst the Health Board accepted that there was a significant failing of care, meriting redress under the relevant complaint handling regulations, …
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202005308 — A GP Practice in the area of Cardiff …
Complained that Practice did not diagnose or refer pt in a timely manner for investigation of abdominal issues – the pt was eventually found to have advanced (colorectal) cancer and sadly died.
PSOW (Public Services Om…
Health
Apr 2021
PSOW-202000416 — Betsi Cadwaladr University Health Board
Mr B complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to diagnose bowel cancel during multiple emergency hospital admissions from August to November 2019. He felt particularly that the Consultant who was mainly in charge of his treatment after his final admission in November should have diagnosed …
PSOW (Public Services Om…
Health
Not Upheld
May 2021
PSOW-202101308 — Cwm Taf Morgannwg University Health Board
Miss X complained that the Health Board had delayed treating her daughter’s injured foot for 3 days. She said the reasons provided to her at the time were untrue and that the delay had caused further suffering and distress for her daughter. In considering the complaint, the Ombudsman noted that …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-201907531 — Hywel Dda University Health Board
Ms M complained on behalf of her friend, Ms A, about the care that Ms A received from the GP Practice and the nurse practitioner in August 2017. The GP had also failed to review Ms A’s anti-psychotic medication. In relation to the Health Board, Ms M’s concerns centred on …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
PSOW-202101445 — Aneurin Bevan University Health Board
Mrs X complained that the Health Board had not provided a response to her complaint submitted to it in December 2020, despite five holding letters being issued. The Ombudsman was concerned by the lack of response. The Health Board agreed to provide Mrs X with a full written response to …
PSOW (Public Services Om…
Health
Jun 2021
PSOW-202001962 — Betsi Cadwaladr University Health Board
Mr B complained that, from 2017, the Health Board failed to conduct appropriate assessments and make suitable referrals following his request to be referred to the Gender Identity Clinic. He also complained about the standard of communication about progress on his request, and said that the Health Board failed to …
PSOW (Public Services Om…
Health
Upheld
Jun 2021
PSOW-202002601 — Betsi Cadwaladr University Health Board
Mrs A underwent a colonoscopy on 12 March 2020 at Ysbyty Gwynedd. She complained that a perforation in her bowel was not identified before she was discharged. Mrs A said that during the procedure her reports of discomfort were not acknowledged and that she was not adequately monitored during recovery. …
PSOW (Public Services Om…
Health
Not Upheld
Jun 2021
PSOW-202001388 — Betsi Cadwaladr University Health Board
Mrs G complained that, as a result of failings in the end-of-life care that her late husband, Mr G, received at Ysbyty Glan Clwyd, his deterioration and death from pneumonia and sepsis was acutely painful and distressing. Mrs G complained that, for the last 2 days of his life, clinicians …
PSOW (Public Services Om…
Health
Upheld
Jul 2021
PSOW-202100430 — Cwm Taf Morgannwg University Health Board
Ms J complained that her father, Mr T, was inappropriately discharged from hospital without having seen a kidney specialist and without full investigations having been carried out, that there were failings in the care and treatment provided to Mr T during a second admission, and that the reasons for his …
PSOW (Public Services Om…
Health
Upheld
Apr 2022
PSOW-202100471 — Betsi Cadwaladr University Health Board
Miss K complained about the care and treatment her mother, Mrs L, received following her admission to Ysbyty Glan Clwyd on 18 June 2020. In particular, Miss K was unhappy about the failure to diagnose Mrs L with cirrhosis of the liver, the failure to treat appropriately and determine whether …
PSOW (Public Services Om…
Health
Upheld
Apr 2022
PSOW-202101075 — Hywel Dda University Health Board
On 27 January 2020 Mrs X was admitted at Withybush General Hospital with a heaviness in her chest, and she was diagnosed with an unstable angina. Two days later Mrs X was seen by a consultant cardiologist who noted her chest pain was relieved by nitrates. Mrs X was transferred …
PSOW (Public Services Om…
Health
Not Upheld
May 2022
PSOW-202105485 — Powys Teaching Health Board
Mrs X complained about the care provided to her husband Mr X, by an English NHS Trust (“the Trust”). The Ombudsman was satisfied that the Health Board had a legal responsibility for Mr X’s care as a resident of Powys who was registered with a GP in Powys. Taking into …
PSOW (Public Services Om…
Health
May 2022
Domestic Homicide Reviews(32)
Kent — recommendation 6
That the NHS Trust, in light of the findings of their investigation, further consider whether the management and governance arrangements currently in place were effective and consider how lessons learnt from this review can be applied for the future.
NHS England
NHS England
Southend-on-Sea — recommendation 1
That NHS England reviews the policies and procedures of the Valkyrie Surgery in respect of domestic abuse and monitors the implementation of any action plan and recommendations, as appropriate.
NHS England
NHS England
Cornwall — recommendation 7
CFT to introduce a policy requiring staff to document information about care and staff involvement at the time of an incident which is reported as a Serious Incident (SI).
NHS Kernow | Cornwall Foundation Partnership …
NHS Kernow
Cumbria — recommendation 18
Cygnet Health Care policies should clearly demonstrate the sign off and governance process.
Cygnet Health Care
Cygnet Health Care
Croydon — recommendation 20
Review the policy and practices around 7 day follow-up email to ensure they meet the requirements of the organisation and comply with national guidance. In the meantime it is recommended that the Assistant Director Patient Safety drafts and distributes a Blue Light Bulletin that clearly states the standard expected for …
South London & Maudsley NHS Foundation …
South London and Maudsley …
Northumberland — recommendation 17
The Trust should ensure that administrative staff have agreed protocols in place regarding pathway management, which should be agreed at the Safe group.
Northumberland, Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Pendle — recommendation 5
That Lancashire and South Cumbria NHS Foundation Trust provides progress updates to Pendle Community Safety Partnership regarding their internal investigation action plan – these will be at 3, 6 and 9 months, with a presentation to the CSP at the 12 months’ stage to assure the CSP of progress, and …
Lancashire and South Cumbria NHS Foundation …
Lancashire and South Cumbria …
Northumberland — recommendation 4
Specialist Care Triumvirate Management Team should further review the clinical practice of those individuals identified by the Investigating Officer and clinical advisors to ensure that the early interventions already initiated in the process of undertaken the review are sufficiently robust to ensure patient safety.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
Ealing — recommendation 4
WLNHS to develop an ERTE system to ensure individual clinicians and their managers are alerted to any cases where risk assessment are falling out of date and that updates are audited.
West London NHS Trust
West London NHS Trust
West Berkshire — recommendation 12
An escalation criterion tool should be implemented, which helps staff consistently identify current and past risk behaviours and triangulate them with other information such as concerns expressed by other professionals. This tool should be regularly audited.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Haringey — recommendation R20
The action plan arising out of this assessment is included in any proposal for reorganisation, and its implementation monitored by Trust Governance procedures.
Camden & Islington NHS Foundation Trust
North London NHS Foundation …
Cornwall — recommendation 7
CFT to introduce a policy requiring staff to document information about care and staff involvement at the time of an incident which is reported as a Serious Incident (SI).
Cornwall Partnership NHS Foundation Trust
Cornwall Partnership Foundation Trust
Lincoln — recommendation 10.4.7
Quality assurance should be improved and managers must be able to produce evidence that cases are being effectively managed and service standards are being complied with.
Lincolnshire County Council Adult Care
Havering — recommendation 3
LFT must review the high-risk report process to provide assurance that staff understands how this can offer support, management advice and senior oversight, and to provide further assurance that the absence of a high-risk report is not a recurring theme in serious incident investigations.
LFT
Wolverhampton — recommendation 13
The Safer Wolverhampton Partnership to require the statutory agencies to demonstrate that services they provide and those they commission, particularly the Black Country Partnership Foundation Trust, and recommend that the Dudley and Walsall Mental Health Partnership NHS Trust, when undertaking Mental Health Assessments under Mental Health Act 1983, exercise their …
Safer Wolverhampton Partnership
Wolverhampton — recommendation 10
The Safer Wolverhampton Partnership to seek assurance from Black Country Partnership Foundation Trust that its guidance for the Care Programme Approach is reviewed and implemented accordingly and evidenced to the Safer Wolverhampton Partnership within 3 months from the date this report is accepted by the Safer Wolverhampton Partnership.
Safer Wolverhampton Partnership
Wolverhampton — recommendation 9
The Safer Wolverhampton Partnership to convene an inter-agency workshop to facilitate a protocol for the development and implementation of Multi-agency Action Plans, to include a dispute resolution process and a review process, and to ensure and monitor its implementation.
Safer Wolverhampton Partnership
Wolverhampton — recommendation 8
The Safer Wolverhampton Partnership to require health service commissioners to demonstrate that they are commissioning services with appropriate and effective discharge planning procedures in place.
Safer Wolverhampton Partnership
Central Bedfordshire — recommendation 1.10.17
The DHR findings will be shared with trust staff via departmental meetings and clinical governance
Luton & Dunstable University Hospital NHS …
Bedfordshire Hospitals NHS Foundation …
Nottingham — recommendation 6.5.2
That the CCG reminds all GP practices about the importance of recording social and environmental issues within the patient records and emphasises the importance of this to patient safety
Nottingham and Nottinghamshire Clinical Commissioning Group
Nottingham and Nottinghamshire Clinical …
Somerset — recommendation v
To act upon the recommendations within the RCA relating to mental health and impatient processes of which all have been actioned and completed.
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Bath and North East Somerset — recommendation R16
Audit of thyroid function test management as proxy for management of blood results
GP Practice
Sefton — recommendation 13
Letters must reflect the risks and the actions taken to mitigate the risk/ highlight further actions needed
Southport and Ormskirk Hospitals NHS Trust
West Berkshire — recommendation 5
Permanent staff should be recruited and supported to manage caseloads based upon evidence-based guidelines and ensuring patient safety at all times.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Liverpool — recommendation 18
Patients attending under the influence of drugs or alcohol should have their capacity to make decisions assessed and recorded.
General Practitioners
Lincoln — recommendation 10.1.4
Provide evidence of a quality assurance process in relation to the effective management of DA cases.
Lincolnshire Police | Addaction | Lincoln …
Lincolnshire Police
Lambeth — recommendation 9.1
Safer Lambeth Chair to forward a copy of this DHR to the Chair and Chief Executive of South London & the Maudsley NHS Foundation Trust for the information of their Board. The Board to consider any further actions required to augment the internal review already presented to them and any …
Safer Lambeth Partnership
New Forest — recommendation 2
Southern Health NHS Foundation Trust to develop and implement an effective domestic abuse policy, that covers all hospital departments, is supported by training and ensures staff are aware of the need to check victims’ safety when disclosures are made, regardless of their relationship to the perpetrator. University Hospital Southampton NHS …
Southern Health NHS Foundation Trust | …
Hampshire and Isle of …
West Berkshire — recommendation 6.12
A response to these recommendations should reflect the guidance provided in the Department of Health publication 292071 “Improving safety, reducing harm, a practical toolkit for front-line practitioners” published in 2009.
NHS Berkshire West
NHS Buckinghamshire, Oxfordshire and …
Stoke-on-Trent — recommendation 7
University Hospital North Midlands (UHNM) should, when disclosures of domestic abuse have been made, always attempt to complete body maps, with the patient’s consent, to note relevant or significant injuries.
University Hospital North Midlands (UHNM)
University Hospitals of North …
Forest of Dean — recommendation 5.2.2c
The Acute Risk Matrix is a dynamic tool and should be updated whenever there is a significant event of concern, as it informs the Risk Management plan for the patient. Patients should have full multidisciplinary reviews, such as Ward Round meetings, at least once a week. Where possible, particularly if …
Elysium Healthcare
Elysium Healthcare
Durham — recommendation 5
The Domestic Abuse and Sexual Violence Executive Group should receive reassurances from health organisations that they have measures in place to audit the use of routine and selective enquiry. This should apply to any cases where practitioners have concerns about the nature of physical injuries presented.
Domestic Abuse and Sexual Violence Executive …
CQC enforcement actions(105)showing 50 strongest matches
Criminal Prosecution: The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
The Care Quality Commission prosecuted The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, which was fined £60,000 after pleading guilty to not providing safe care and treatment. This exposed a patient to significant risk of avoidable harm due to …
Dec 2022
Criminal Prosecution: University Hospitals of Derby and Burton NHS Foundation Trust
The Care Quality Commission brought a prosecution against University Hospitals of Derby and Burton NHS Foundation Trust. The trust pleaded guilty to failing to provide safe care and treatment to a patient, causing them avoidable harm. Following a sentencing hearing, …
Mar 2023
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
The CQC inspected an acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital in May. Inspectors found that staff could not observe patients in all parts of the ward, recording of patient observations were …
Fulbourn Hospital, Cambridge
Jul 2022
Warning Notice: West London NHS Trust
CQC told West London NHS Trust to make improvements to its community-based mental health services following an inspection in May. The inspection found significant staffing issues and delays to people accessing treatment, which put some people at risk of harm. …
Jul 2022
Conditions Imposed: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission placed conditions on University Hospitals Birmingham NHS Foundation Trust's registration. This action followed inspections where the trust had not met the requirements of a previous warning notice and further issues were identified. Conditions were also imposed …
Feb 2024
Warning Notice: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission (CQC) served University Hospitals Birmingham NHS Foundation Trust with a warning notice following inspections carried out in December. CQC found that the trust needed to make significant and immediate improvements to its staffing levels in medical …
Good Hope Hospital
Apr 2023
Warning Notice: Nottinghamshire Healthcare NHS Foundation Trust
The Care Quality Commission (CQC) issued requirement notices to Nottinghamshire Healthcare NHS Foundation Trust following inspections from October to December last year. CQC found improvements were needed in the trust's acute wards for adults of working age and psychiatric intensive …
Mar 2024
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) found improvement is needed in the children and young people’s (CYP) services run by Kettering General Hospital NHS Foundation Trust, after an inspection in December. Due to concerns found at this inspection, CQC has taken …
Kettering General Hospital
Apr 2023
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, telling it to make urgent improvements. This followed an inspection in March which found a decline in the quality of care provided, …
Oct 2025
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) took enforcement action, serving Greater Manchester Mental Health NHS Foundation Trust with two Section 29A warning notices. One notice related to ligature and fire risks, and the other to staffing and governance, requiring significant improvements …
Nov 2022
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued Gloucestershire Hospitals NHS Foundation Trust with a warning notice following an inspection of its surgical services. The inspection was undertaken in response to concerns received about the safety and quality of the services, including …
Cheltenham General Hospital and Gloucestershire R…
Oct 2022
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) served Essex Partnership University NHS Foundation Trust with a warning notice following an inspection of two acute wards for adults of working age. The inspection raised serious concerns about patient safety, including staff not always …
acute wards for adults of working age
Apr 2023
Warning Notice: Leeds and York Partnership NHS Foundation Trust
The Care Quality Commission (CQC) re-rated the long stay or rehabilitation mental health wards for working age adults, run by Leeds and York Partnership NHS Foundation Trust, as requires improvement. Following an inspection on 10 and 11 March, CQC found …
Asket Croft, Asket House and Newsam Centre Ward
Jul 2026
Warning Notice: Surrey and Sussex Healthcare NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Surrey and Sussex Healthcare NHS Trust following an inspection in November last year. CQC found a breach of regulations relating to how the trust is managed and downgraded its leadership …
Jul 2026
Conditions Imposed: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission imposed conditions on Greater Manchester Mental Health NHS Foundation Trust following an unannounced inspection in March 2024. The conditions require the trust to make improvements in specific areas, including effective service management, ensuring a clean, smoke-free …
Acute wards for adults of working age and psychia…
Dec 2024
Criminal Prosecution: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission brought a prosecution against Shrewsbury and Telford Hospital NHS Trust, which was ordered to pay a total of £1,375,712 after pleading guilty to failing to provide safe care and treatment to two patients, causing them avoidable …
Royal Shrewsbury Hospital
May 2022
Conditions Imposed: Mid and South Essex NHS Foundation Trust
The Care Quality Commission (CQC) placed conditions on Basildon University Hospital’s registration following inspections of its medical care and urgent and emergency services between December 2024 and March 2025. CQC found serious overcrowding in the emergency department, risking people’s safety, …
Basildon University Hospital
Oct 2025
Warning Notice: Countess of Chester Hospital NHS Foundation Trust
The Care Quality Commission rated Countess of Chester Hospital NHS Foundation Trust as 'requires improvement' and took enforcement action following an inspection in February and March. CQC served the trust with two warning notices, requiring urgent improvements in the effectiveness …
Jun 2022
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) told Barts Health NHS Trust that improvements are needed in the diagnostic imaging departments at The Royal London Hospital and Whipps Cross University Hospital. Following a focused inspection in May, CQC found serious concerns including …
The Royal London Hospital and Whipps Cross Univer…
Jul 2021
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC has told County Durham and Darlington NHS Foundation Trust that it must make immediate improvements to the quality and safety of care it’s providing, and has downgraded its well-led rating from good to inadequate following an inspection from 2 …
Dec 2025
Warning Notice: Southern Health NHS Foundation Trust
The Care Quality Commission issued a warning notice to Southern Health NHS Foundation Trust following an inspection in January 2016. The inspection found the Trust had not put in place robust governance arrangements to investigate incidents, including deaths, and had …
Evenlode, Oxfordshire and Kingsley ward at Melbur…
Apr 2016
Warning Notice: Plymouth Hospitals NHS Trust
Following a visit to Derriford Hospital, the Care Quality Commission found that important check-lists recommended by the World Health Organisation and the National Patient Safety Agency were not being used effectively by surgical teams. The CQC required Plymouth Hospitals NHS …
Derriford Hospital
Feb 2011
Warning Notice: Berkshire Healthcare NHS Foundation Trust
Following a review, the Care Quality Commission found that incidents concerning patient safety were not being reported quickly enough to the National Patient Safety Agency. The CQC required that the trust address this issue by 23 March, stating that if …
Mar 2011
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: Central and North West London NHS Foundation Trust
The Care Quality Commission formally warned Central and North West London NHS Foundation Trust that it must improve the care it provides at the Campbell Centre, Milton Keynes, and 3 Beatrice Place, Kensington. At the Campbell Centre, warning notices were …
Campbell Centre, Milton Keynes and 3 Beatrice Pla…
Mar 2014
Warning Notice: Southern Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Southern Health NHS Foundation Trust, requiring significant improvements to protect patients in its mental health and learning disability services. CQC found that the Trust did not operate effective governance arrangements …
Apr 2016
Warning Notice: Sheffield Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Sheffield Teaching Hospitals NHS Foundation Trust following an inspection in October and November. The inspection found deterioration in the quality of services, leading to the trust's overall rating dropping to …
Apr 2022
Warning Notice: Salisbury NHS Foundation Trust
The Care Quality Commission (CQC) told Salisbury NHS Foundation Trust that improvements needed to be made in its maternity and spinal services at Salisbury District Hospital following an inspection on 31 March 2021. CQC found that governance arrangements were not …
Salisbury District Hospital
Jul 2021
Warning Notice: Nottingham University Hospital NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Nottingham University Hospital NHS Trust following an inspection in June and July. CQC found areas where improvements were needed, particularly around leadership, risk management, governance, and culture. Concerns included a …
Sep 2021
Warning Notice: Liverpool University Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) told Liverpool University Hospitals NHS Foundation Trust to take immediate action to improve the safety of some of its services following two inspections. Inspectors found a lack of effective systems to ensure all patients received …
Jan 2021
Conditions Imposed: The Hillingdon Hospital NHS Foundation Trust
The Care Quality Commission (CQC) used its urgent enforcement powers by placing conditions on The Hillingdon Hospital NHS Foundation Trust's registration. This action was taken in response to safety concerns following an inspection on 4 and 5 August 2020, which …
Sep 2020
Warning Notice: Norfolk and Suffolk NHS Foundation Trust
The Care Quality Commission (CQC) served Norfolk and Suffolk NHS Foundation Trust a warning notice following an inspection in November and December. The inspection found deterioration in the quality and safety of patient care in most services, exposing patients to …
Apr 2022
Warning Notice: Colchester Hospital University NHS Foundation Trust
During an inspection in September and October 2015, CQC inspectors found Colchester Hospital University NHS Foundation Trust needed to make a number of urgent improvements. Following this, CQC issued a letter to the trust highlighting the urgent improvements required to …
Jan 2016
Warning Notice: St George’s University Hospitals NHS Foundation Trust
Immediately after an inspection in June and July 2016, CQC issued a Warning Notice to St George’s University Hospitals NHS Foundation Trust. This notice highlighted breaches in regulations concerning safe and fit premises at St George’s Hospital, obtaining consent under …
Tooting, south west London
Nov 2016
Warning Notice: Worcestershire Acute Hospitals NHS Trust
Following a focused inspection in April 2017, CQC issued a Warning Notice to Worcestershire Acute Hospitals NHS Trust. The notice requires the trust to take action to address concerns regarding governance systems and the mitigation of risks. Inspectors found no …
Aug 2017
Warning Notice: Barts Health NHS Trust
Section 29A warning notice served on maternity services at The Barkantine Centre, a birth centre on the Isle of Dogs, following a short-notice focused inspection on 17 August 2022. CQC rated the service inadequate and required the trust to take …
The Barkantine Centre
Aug 2022
Warning Notice: Sandwell and West Birmingham Hospitals NHS Trust
Section 29A warning notice covering maternity services at City Hospital, Birmingham, following an inspection in June 2024 after which the safe rating declined from good to inadequate. The notice focused the trust's attention on making significant improvements around the environment, …
City Hospital, Birmingham
Nov 2024
Warning Notice: Maidstone and Tunbridge Wells NHS Trust
Section 29A warning notice covering maternity services at The Tunbridge Wells Hospital at Pembury, following inspections in August 2023 that rated the service inadequate. CQC took action to protect people and issued the notice emphasising the urgent need for rapid …
The Tunbridge Wells Hospital at Pembury
Feb 2024
Warning Notice: University Hospitals of North Midlands NHS Trust
Section 29A warning notice covering maternity services at Royal Stoke University Hospital, following an inspection on 7 March 2023 after which the safety rating dropped to inadequate. The notice required significant improvements to the safety of the service. A focused …
Royal Stoke University Hospital
Mar 2023
Warning Notice: County Durham and Darlington NHS Foundation Trust
Section 29A warning notice issued on 28 April 2023 covering maternity services at the University Hospital of North Durham and Darlington Memorial Hospital, following an inspection in March 2023. The safe and well-led ratings at both hospitals declined from good …
University Hospital of North Durham and Darlingto…
Apr 2023
Warning Notice: East and North Hertfordshire NHS Trust
Section 29A warning notice served on the maternity service at the Lister Hospital, Stevenage. CQC rated the service inadequate and issued the notice to focus the trust's attention on rapid improvement, stating that women and babies were not receiving the …
Lister Hospital, Stevenage
Jan 2023
Warning Notice: Barts Health NHS Trust
Section 29A warning notice served on maternity services at Newham University Hospital. A CQC inspection in September 2018 rated the hospital's maternity service inadequate overall, with concerns that the systems to assess, monitor and mitigate risks to patients and the …
Newham University Hospital
Oct 2018
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
Updated Section 29A warning notice issued for maternity services following an inspection in March 2024.
Mar 2024
Warning Notice: Bedfordshire Hospitals NHS Foundation Trust
Warning notice served on maternity and midwifery services at Luton and Dunstable Hospital for failing to meet the regulations on safe care and treatment and on governance and quality assurance oversight.
Oct 2025
Warning Notice: Nottinghamshire Healthcare NHS Foundation Trust
Section 29A warning notice for failing to meet regulations on the governance of long-term segregation environments at Rampton Hospital and Arnold Lodge.
Nov 2025
Criminal Prosecution: Tees, Esk and Wear Valleys NHS Foundation Trust
The trust pleaded guilty to two charges of failing to provide safe care and treatment to two patients, including Christie Harnett, who died at West Lane Hospital in June 2019. Ordered to pay £215,170 in total. A separate CQC prosecution …
Apr 2024
£200000
Criminal Prosecution: The Rotherham NHS Foundation Trust
The trust pleaded guilty to one charge of failing to provide safe care and treatment, exposing four young children and other patients to a significant risk of avoidable harm at Rotherham General Hospital. Ordered to pay £233,238 in total.
Oct 2022
£200000
Criminal Prosecution: Nottingham University Hospitals NHS Trust
Second CQC prosecution of the trust. It pleaded guilty to six charges of failing to provide safe care and treatment to three mothers and their babies in its maternity services, including Daniela O'Sullivan and baby Adele O'Sullivan. Ordered to pay …
Feb 2025
£1600000
Criminal Prosecution: Nottingham University Hospitals NHS Trust
The trust pleaded guilty to two charges of failing to provide safe care and treatment to Sarah Andrews and her baby Wynter Andrews, who died shortly after birth in September 2019. At the time the highest fine imposed for failings …
Jan 2023
£800000
Conditions Imposed: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission imposed conditions on Tees, Esk and Wear Valleys NHS Foundation Trust's registration in August 2019. This action followed an inspection of the trust’s child and adolescent mental health wards (CAMHS) in June 2019, which were rated …
Aug 2019
MNSI reports(3)
Safety spotlight: Reviewing and actioning laboratory test results
Safety spotlight on the review and actioning of laboratory test results in maternity care.
Themed Review
May 2025
MNSI Annual Report and Recommendations 2024/25
Annual report of the Maternity and Newborn Safety Investigations programme. MNSI progressed 618 investigations in 2024/25 and made 1,122 safety recommendations to 126 organisations. The programme has completed more than 4,000 investigations to date and works with all 120 trusts …
Annual Report
Safety spotlight: Maternal deaths in the first trimester from venous thromboembolism (VTE)
Safety spotlight on maternal deaths in the first trimester from venous thromboembolism.
Themed Review
Feb 2025