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 14 independent accountability sources, so the source mix matters as much as the headline total.
293 inquiry recs
172 PFD reports
27 committee recs
329 HSSIB recs
394 CQC actions
7 PHSO recs
13 IMB recs
2 patient safety alerts
1 Scottish FAI
5 Article 2 learning points
1 detention investigation rec
20 PHSO decisions
444 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(293)— showing 50 strongest matches
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 …
Response Pending
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. …
Response Pending
R81 — Expert clinical governance advisory function
Recommendation: The DoH should establish an expert clinical/social governance advisory function to support providers.
Response Pending
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 …
Response Pending
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.
Response Pending
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 …
Response Pending
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 …
Response Pending
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F46 — Use of information about compliance by regulator from: Quality and risk profiles
Recommendation: The Quality and Risk Profile should not be regarded as a potential substitute for active regulatory oversight by inspectors. It is important that this is explained carefully and clearly as and when the public are given access to the information.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F45 — Use of information about compliance by regulator from: Inquests
Recommendation: The Care Quality Commission should be notified directly of upcoming healthcare-related inquests, either by trusts or perhaps more usefully by coroners.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F44 — Use of information about compliance by regulator from: Media
Recommendation: Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for the trust concerned to demonstrate that the learning to be …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F43 — Use of information about compliance by regulator from: Media
Recommendation: Those charged with oversight and regulatory roles in healthcare should monitor media reports about the organisations for which they have responsibility.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F41 — Use of information about compliance by regulator from: Patient safety alerts
Recommendation: The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F40 — Use of information about compliance by regulator from: Complaints
Recommendation: It is important that greater attention is paid to the narrative contained in, for instance, complaints data, as well as to the numbers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F39 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should introduce a mandated return from providers about patterns of complaints, how they were dealt with and outcomes.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F38 — Use of information about compliance by regulator from: Complaints
Recommendation: The Care Quality Commission should ensure as a matter of urgency that it has reliable access to all useful complaints information relevant to assessment of compliance with fundamental standards, and should actively seek this information out, probably via its local …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F37 — Use of information about compliance by regulator from: Quality accounts
Recommendation: Trust Boards should provide, through quality accounts, and in a nationally consistent format, full and accurate information about their compliance with each standard which applies to them. To the extent that it is not practical in a written report to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F36 — Use of information for effective regulation
Recommendation: A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F35 — Need to share information between regulators
Recommendation: Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F34 — Interim measures
Recommendation: Where a provider is under regulatory investigation, there should be some form of external performance management involvement to oversee any necessary interim arrangements for protecting the public.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F33 — Interim measures
Recommendation: Insofar as healthcare regulators consider they do not possess any necessary interim powers, the Department of Health should consider introduction of the necessary amendments to legislation to provide such powers.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F32 — Interim measures
Recommendation: Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F6 — Clarity of values and principles
Recommendation: The handbook to the NHS Constitution should be revised to include a much more prominent reference to the NHS values and their significance.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F5 — Clarity of values and principles
Recommendation: In reaching out to patients, consideration should be given to including expectations in the NHS Constitution that: Staff put patients before themselves; They will do everything in their power to protect patients from avoidable harm; They will be honest and …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F4 — Clarity of values and principles
Recommendation: The core values expressed in the NHS Constitution should be given priority of place and the overriding value should be that patients are put first, and everything done by the NHS and everyone associated with it should be informed by …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
AFA-7B — Cancer Services
Recommendation: The Trust has worked through a detailed action plan relating to Cancer Services, specifically in relation to the oversight and support for MDTs and has addressed the issues identified in the SAIs in urology. Extending the work to include dimensions …
Response Pending
R12 — Single written channel for serious incident reports
Recommendation: We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved (para 5.14.12)
Unknown
R11 — Incident report on monitoring alarm failure
Recommendation: We recommend that in the event of failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again (para 5.11.6).
Unknown
Prevention of Future Deaths reports(172)— showing 50 strongest matches
Bertha Cray
Concerns: Inadvertent alteration of 'nil by mouth' signage is possible due to easily turned double-sided signs and an unclear cause of previous alteration, risking recurrence.
Response (Barts Health NHS Trust): The Trust has stopped using double-sided 'nil-by-mouth' signs with different instructions on each side, and will now issue signs with the same instruction on both sides. The family has been …
Responded
Kirabo Kiwanuka
Concerns: Significant disagreement among medical professionals on Neuroleptic Malignant Syndrome diagnosis and management, leading to unclear optimal care pathways and limited family involvement for sectioned patients with acute medical issues.
Overdue
John Fox
Concerns: Reduced physiotherapy services on bank holidays and weekends increase the risk of post-operative complications for vulnerable patients.
Overdue
Barry Dillion
Concerns: Insufficient resources are available to provide a comprehensive Speech and Language Therapy service at the hospital, potentially impacting patient care.
Overdue
Nellie Travis
Concerns: The hospital's Falls Risk Assessment tool is ineffective due to its subjective nature and inconsistent application by nursing staff, highlighting the need for a more objective assessment method.
Overdue
Stephen Ellis
Concerns: A lack of warfarin home management kits for high-risk post-heart surgery patients leads to reliance on less efficient hospital monitoring.
Overdue
Neil Carter
Concerns: There were repeated failures in basic nursing observations, chronic inadequate staffing and skill mix, and deliberate falsification of nursing records, compounded by management's failure to address reported issues.
Response (CQC): The CQC will include information held on deaths in psychiatric detention in all future annual reports. They will also work with partners in developing the Mental Health Crisis Care Concordat …
Response (Priory Group): The organisation disciplined and dismissed a nurse for falsifying records and referred them to the NMC. They have also implemented changes to the staff induction programme and introduced daily monitoring …
Responded
Natasha Raghoo
Concerns: The coroner identified concerns regarding staff training in cardiopulmonary resuscitation and defibrillator use, sporadic physical observations, the lack of routine ECGs for patients on antipsychotics with raised blood pressure, inconsistent communication during staff handovers, and unclear policies on family involvement in care planning.
Response (Partnership in Care): Partnership in Care reports improvements in information flow between PiC and SLaM, including a Liaison Nurse attending The Dene from SLaM several days a week utilizing a VPN link. PiC …
Overdue
Jean James
Concerns: Initial documentation delays and the unreviewed omission of prophylactic medication occurred. Pharmacy queries were poorly communicated, indicating that existing systems and protocols may be insufficiently robust to prevent human factor failures.
Response (City Hospitals Sunderland): The hospital information system is being updated to require completion of VTE prescriptions for at-risk patients, with alerts on medication administration records. A new format for clinical handover from the …
Responded
John Adams
Concerns: VERONICA HAMILTON-DEELEY, LLB.
Overdue
Lana-Liza Chervonenko
Concerns: High activity on the labour ward led to delayed medical reviews, incorrect emergency grading, incomplete patient assessments, and a flawed prioritisation decision, resulting in significant delays to emergency delivery.
Overdue
Ronald Smith
Concerns: There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
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): Brighton and Sussex University Hospitals NHS Trust has integrated the neck of femur service at the Princess Royal Hospital. They also recruited a new Clinical Nurse Practice Educator and implemented …
Overdue
Karen O’Brien
Concerns: The mental health service (SEPT) made clinical determinations without adequate inquiry or face-to-face assessment, overriding a GP's referral. The coroner questioned the rigid application of NICE guidelines.
Overdue
Mary James
Concerns: Inadequate INR monitoring, uncertainty regarding Warfarin intake, and poor communication between healthcare providers led to unadjusted anticoagulation therapy for a dementia patient, missing a critical hospital admission opportunity.
Overdue
Eileen Smith
Concerns: The report detailed gross failings of nursing care for a patient with a learning disability and highlighted the risk of making assumptions about health based on external appearance, stressing the need for better communication with carers.
Response (Department of Health): The response acknowledges the concerns raised and references existing guidance and resources, including work by NHS England, NICE and the NPSA, but describes no specific actions taken or planned by …
Responded
Barry Pike
Concerns: The specific matters of concern are detailed in an external report by Dr Stephen Hoole, which was not provided here.
Overdue
Sharon Henshall
Concerns: The absence of a VTE risk assessment tool in the Emergency Department for patients discharged with lower limb immobilisation, coupled with varied national guidance, creates a 'postcode lottery' for prophylaxis.
Overdue
Frederick Sutton
Concerns: Suboptimal staffing, poor staff training in drug administration and cardiac arrest response, unread nursing notes, incompatible computer systems, and inaccurate patient information contributed to systemic care failures.
Overdue
Rosalind Baird
Concerns: There is no formal national monitoring scheme for inexperienced surgeons, despite the existence of effective local models, risking patient safety during surgical procedures.
Overdue
Rebecca Jones
Concerns: Concerns involved the failure to conduct a Section 136 mental health assessment within the expected three-hour timeframe, and the need for facilities to ensure safe containment for vulnerable individuals.
Response (Department of Health): NHS England will spend £15m in 2016/17 to boost provision in areas that lack adequate health-based places of safety and is developing commissioning guidance for effective crisis response. HEE is …
Responded
Brian Shillinglaw
Concerns: The provided text is incomplete and does not contain specific concerns.
Overdue
Darren Jones
Concerns: The report identifies a need for review of protocols regarding when renal advice should be sought, especially for transplant patients, along with the education of staff and availability of immunosuppressant drugs.
Overdue
Thelma Clarkson
Concerns: The NICE Head Injury Pathway fails to include Clopidogrel as a trigger for CT scans, unlike Warfarin, despite its known bleeding risk. This omission can lead to missed diagnoses and delayed treatment.
Overdue
Stephen Adams
Concerns: Mental Health Liaison Team risk assessment forms are inadequately completed, with the suicide risk box frequently left blank. This leads to crucial risk information not being properly recorded or easily identifiable.
Overdue
Bryan Catanach
Concerns: Significant communication failures between clinicians and staff led to delays in patient transfer, senior review, and confusion over care instructions. Additionally, inadequate patient supervision resulted in a fall, and essential traction equipment was unavailable.
Response (Bryan Catanach): The Trust has refreshed communication processes for emergency patients, ring-fenced a spinal emergency bed, and expanded on-site spinal equipment with a central store, enhanced register, and pictorial training folder. They …
Responded
Lincoln Brady
Concerns: Conflicting examination results during labour were not adequately investigated, leading to an undiagnosed breach presentation and preventing appropriate planning for delivery.
Response (South Tees Hospitals NHS Foundation Trust): The Trust has implemented presentation scanning for women in labour, with a training and skills maintenance programme for midwives. The partogram will include a section for documenting scan results, and …
Responded
June Parkes
Concerns: Significant delays occurred in urgent endoscopies due to inadequate protocols for 'in-hours' care and re-bleeds, and a lack of 'out-of-hours' emergency endoscopy/surgery. Concerns also include poor record-keeping, NEWS compliance, and doctor presence during critical transfers.
Overdue
Alwyn Head
Concerns: Failures included not establishing MRSA history, withholding prophylactic antibiotics, lacking a post-operative wound care plan, and providing meaningless wound documentation, compromising patient safety.
Response (A head): The Trust introduced new admission/transfer documentation for patient infection status, is providing staff training, and implemented ward-to-board rounds. A Deteriorating Patient Programme and a Sepsis Action Group are in place, …
Responded
Dorothy Imisson
Concerns: The District Nursing Service compromised patient care by failing to develop appropriate care plans and not following NMC guidance for record-keeping or NICE clinical guidelines.
Overdue
Milly Zemmel
Concerns: There were gross failures in applying the falls risk policy, escalating clinical review, providing one-to-one supervision, and handing over critical patient information, leading to an unsupervised, vulnerable patient falling. The internal investigation was also inadequate.
Response (Response Pennine Acute Hospitals): The Trust has revised its Incident Reporting and Investigation Policy, launched an Enhanced Patient Observation Policy, and will include failure to escalate lack of medical review in the Lessons Learned …
Responded
Amanda Coulthard
Concerns: Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
Response: The Department of Health acknowledges concerns about nasogastric tube misplacement and refers to ongoing work, including an NIHR-funded project at the University of Hull to develop a location-indicating NGT.
Response (North Cumbria University Hospitals Trust): The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 …
Responded
Michael Parke
Concerns: Recurring avoidable deaths from misplaced nasogastric tubes revealed staff unaware of or not applying the relevant policy, the trust not ensuring compliance or providing training, and a failure to learn from previous incidents, compounded by a lack of corporate memory.
Response: The Department of Health acknowledges the need for consistent implementation of patient safety requirements for nasogastric tubes. They are considering the evidence and economic implications of routine pH testing and …
Response (North Cumbria University Hospitals Trust): The Trust has created an action plan in response to the concerns raised, summarised in an attached report. Progress will be included in the Trust’s Internal Audit Plan for 2017/18 …
Responded
Kathleen Cooper
Concerns: A medical practitioner raised concerns regarding the difficulties faced by clinicians in different sites of an acute NHS Trust, with errors and missed opportunities to treat the deceased, and poor communication between clinicians and nurses.
Overdue
Anna Walker
Concerns: Post-operative checks were not compliant with protocol, leading to delayed detection of a bleed, due to failures in portering, ward nurse responsibilities, and unclear clinical accountability. The incident was also inappropriately downgraded.
Overdue
Annette Krasinsky-Lloyd
Concerns: Inadequate A&E governance, including an unsupervised SHO and delayed consultant involvement, led to critical delays in patient assessment, test results, anti-coagulation reversal, transfusions, and caused poor intravenous access.
Overdue
Caliel Smith-Kwami
Concerns: Critical insulin and amino acid results were delayed due to lab analyser faults and unchased; the electronic record system failed to alert clinicians to new results, hindering diagnosis before discharge.
Response (Barts Health NHS Trust): Barts Health NHS Trust has reviewed and approved contingency plans for laboratory analyser faults, and implemented a system of rotational consultant checks to ensure results are chased. They clarified that …
Responded
Barry Tucker
Concerns: No specific concerns were detailed in the provided text.
Response (East Sussex Healthcare NHS Trust): The Trust will not accept bookings for major urology cancer surgery patients on the private patient unit. The urology specialty will conduct documentation audits to identify themes and improvements, and …
Responded
Frank Hayward
Concerns: Emergency Department failures included incorrect injury assessment, missed specialist review opportunities, poor equipment provision systems, inadequate inter-departmental communication, and significant CT scan delays.
Response (Frank Hayward): • The guideline for diagnostic testing and treatment of head injuries has been revised in line with NICE Clinical Guideline (CG176). • The head injury proforma now includes a checklist …
Responded
Lea Hunsley
Concerns: The care facility lacked an SUI protocol, and staff demonstrated inadequate skills in identifying and escalating deteriorating patients, poor observation, and insufficient use of care records.
Response (EAM Care Group): EAM Care Group completed a root cause analysis with commissioners, will obtain post-operative care plans prior to admission, and introduced new handover procedures including lunchtime handovers and archiving of staff …
Responded
Marian Grant
Concerns: Failure to prescribe VTE prophylaxis due to electronic patient record (EPR) issues and inadequate safeguards for trauma patients on non-trauma wards, coupled with ineffective EPR alerts, increased the risk of avoidable death.
Response (Marion Grant): • The Trust had undertaken an RCA investigation and provided an updated action plan following the death of Mrs Grant. • The Trust had already put in place several measures …
Responded
Hubert Kelly
Concerns: Emergency department overcrowding leads to patients waiting in corridors without meaningful interaction or timely assessment, with waiting times frequently exceeding national standards.
Response (Hubert Kelly): The Trust has expanded its triage area, implemented a 24/7 Clinical Support Worker for waiting room oversight, and introduced an escalation plan with increased physician presence and additional support for …
Overdue
Rita Giles
Concerns: The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Overdue
Ronald Harman
Concerns: The provided text indicates general concerns about matters revealed during the inquest, suggesting a risk of future deaths without specifying particular issues.
Overdue
John Waite
Concerns: Inadequate visual observation protocols following central venous catheter removal, with only 5-minute dressing checks risking significant, rapid blood loss, compounded by a lack of national guidelines for this procedure.
Response (John Waite Response2): The Trust raised awareness of the issue with national renal bodies and will revise protocols based on forthcoming guidance. For electronic records, they have incorporated a 'date and time seen' …
Response (John Waite): The Department of Health and Social Care has issued an interim advisory alert to renal units on reviewing practices for central venous catheter removal. They are also establishing an expert …
Overdue
Angela Jackson
Concerns: A critical absence of clear, documented national and regional pathways for aortic aneurysm referrals, including correct hospital names and contact details, leads to inefficient and potentially delayed emergency treatment.
Response (Angela Jackson Response2): The Department of Health and Social Care confirms NHS England has commissioned work for national clinical reference groups to produce a new service specification for the surgical management of aortic …
Response (Angela Jackson): The Trusts have established a joint working group that has developed interim guidance for managing Thoracoabdominal Aortic Aneurysms and Type A dissection, which is currently undergoing consultation and modification.
Overdue
Stephen Taylor
Concerns: Neurosurgical patients lacked consultant physician support, leaving junior doctors to manage complex medical issues. An unclear alcohol withdrawal protocol led to incorrect medication prescriptions.
Response (Stephen Taylor): The Trust uses electronic referral systems and junior doctor rotations for multi-specialty opinions. They have already supplemented their Care of the Elderly team with Advanced Nurse Practitioners to support complex …
Responded
Mary Ryder
Concerns: Post-operative care failed to provide sufficient anticoagulation therapy and clinical review for a patient with decreased mobility, and NICE guidance for D-dimer testing was not followed.
Response (Department of Health Social Care): The Department of Health and Social Care (DHSC) consulted NICE, who advised that existing guidelines on VTE prophylaxis and management are adequate and do not require amendment.
Responded
Joseph Page
Concerns: Hospital policies for storing patients' own medication were breached, allowing a patient unsupervised access to prescription drugs which led to an overdose.
Overdue
John Kirby
Concerns: Evidence from the inquest revealed matters of concern and a risk of future deaths, necessitating action.
Response (Sussex NHS Trust): Sussex Partnership NHS Foundation Trust has reduced the lead practitioner's caseload, implemented an information-sharing protocol between mental health liaison team and Pavillions A&E to improve communication, shared the ADHD NICE …
Overdue
Select committee recommendations(27)
#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 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date: April 2026 4.2 The department and NHS England will continue to prioritise patient safety and a learning culture across the NHS so that harmful …
Not Addressed
#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 …
Gov response: The government agrees with the Committee’s recommendation. learning culture across the NHS so that harmful patient events are significantly reduced. This includes ongoing work to progress key measures under the NHS Patient Safety Strategy, which …
Accepted
#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 …
Gov response: 3. PAC conclusion: We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. 3a. PAC recommendation: The Department should establish …
Not Accepted
#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 …
Gov response: 2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2e. PAC recommendation: The Department and NHS England should have a clear system of accountability for patient …
Accepted
#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 …
Gov response: 2. PAC conclusion: The NHS has not done enough to tackle the underlying causes of harm to patients. 2a. PAC recommendation: The Department must set a national framework for improving patient safety with clear targets …
Accepted
#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 …
Gov response: The government disagrees with the Committee’s recommendation The wider question around the health economics of patient safety will be explored as part of the forthcoming update to the NHS Patient Safety Strategy by working with …
Not Accepted
#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 …
Gov response: The government agrees with the Committee’s recommendation. Maternity and Neonatal Investigation will publish its final report and national recommendations in June 2026. This investigation is independent of government. Prior to publishing a final report and …
Accepted
#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. …
Gov response: We agree that this should be remedied and committed in the previous house to continue work on this issue. The Government tabled an amendment at Commons Committee, which seeks to address issues with the variations …
Position Not Stated
#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. …
Gov response: We agree that this should be remedied and committed in the previous house to continue work on this issue. The Government tabled an amendment at Commons Committee, which seeks to address issues with the variations …
Accepted
#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.
Gov response: 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. …
Accepted
#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
Gov response: Accept in principle. The Government agrees that patient involvement in services is important, and that this should be taking place in all areas of health and care. The Care Quality Commission’s assessments of Integrated Care …
Accepted
#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 …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: Autumn 2026 The rising cost of clinical negligence and experience of patients navigating the system are of great concern to government and ministers are committed …
Response Pending
#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.
No Published Response
#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, …
No Published Response
#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 …
Gov response: 130. We accept this recommendation. 131. NHSEI agrees that caesarean section rates should not be used to performance manage Trusts and supports the use of the Robson criteria to measure caesarean section rates more intelligently. …
Accepted
#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 …
Gov response: 106. The Government accepts this recommendation in part. 107. The NHS Mandate7 sets out an aim of year on year reductions in the difference in the stillbirth and neonatal mortality rate per 1,000 births between …
Partially Accepted
#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.
Gov response: 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. …
Under Consideration
#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.
Gov response: The government accepts this recommendation. NHS England is developing proposals for implementing surge capacity plans in the NHS, taking into account the lessons learned from the COVID-19 pandemic. These proposals will consider a range of …
Accepted
#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 …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented NHS SC engages clinicians in all sourcing decisions. Lead trusts are used to ensure the voice of the clinical workforce is at the forefront of understanding …
Accepted
#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 …
Partially Accepted
#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 …
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 …
Response Not Attributed
#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 …
Gov response: 159. We accept this recommendation. 160. A single data set now collects all the information from both NHS and private sector services and is completed by all providers. It is able to analyse at a …
Accepted
#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 …
Gov response: We accept this recommendation. A single data set now collects all the information from both NHS and private sector services and is completed by all providers. It is able to analyse at a provider and …
Response Not Attributed
#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 …
Gov response: Accept in principle. The Government agrees that patient involvement in services is important, and that this should be taking place in all areas of health and care. The Care Quality Commission’s assessments of Integrated Care …
Accepted
#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 …
Gov response: 3.2 As a Government, we recognise that leaders and senior managers are central to creating a supportive, healthy and compassionate workplace culture. The NHS People Plan recognises that the most effective route to making change …
Accepted
#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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Recommendation implemented 3.2 The NHS has been at the forefront of the public sector response to RAAC and has been surveying sites since 2019. The department will …
Not Addressed
#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 …
Gov response: The government disagrees with the Committee’s recommendation. The government agrees that NHP should test Hospital 2.0, its standardised approach to building hospitals, and intends to do so at the earliest opportunity within one of the …
Not Accepted
HSSIB safety recommendations(329)— showing 50 strongest matches
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
Electronic patient record systems – electronic referrals for ongoing care
Use of advice and guidance may introduce risks to patient safety and how they may be mitigated.
Investigation Scope
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
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that the Centre for Perioperative Care considers the remit of the National Safety Standards for Invasive Procedures (NatSSIPs) to cover the administration of general or regional anaesthesia for non-invasive diagnostic procedures.
Safety Recommendation
CQC inspection actions(394)— 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
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 must ensure the risks associated with reported safety concerns are mitigated promptly.
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
The Queen Elizabeth Hospital
The service should ensure all incidents are investigated in a timely way.
Should Do
The Princess Royal Hospital
The trust should ensure the governance system in place is effectively supporting all aspects of safe, quality care.
Should Do
The Princess Royal Hospital
The trust should ensure checks on resus trolley are recorded as per policy.
Should Do
The Princess Royal Hospital
The trust should consider reviewing the governance structure throughout the organisation in order to ensure that only relevant information is presented to trust board.
Should Do
The Princess Royal Hospital
The service must operate effective governance systems to ensure compliance with all relevant sections, such as but not limited to the risk register.
Must Do
The Princess Royal Hospital
The trust must ensure that staff comply with nationally recognised infection control standards.
Must Do
The County Hospital
The service should consider how it uses patient identification, such as wristbands, to determine if this is working effectively.
Should Do
The County Hospital
The provider must ensure there are systems and processes to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities. It must assess, monitor and mitigate the risks relating to …
Must Do
St Richard's Hospital
The service must review its existing IPC audit monitoring systems to identify any shortfalls in infection prevention and control and so action can be taken to make improvements when needed.
Must Do
St Richard's Hospital
The trust must ensure that the systems used to monitor WHO checklist compliance, including brief and debrief, are effective in demonstrating compliance and able to show areas for improvement effectively in line with NPSA guidance.
Must Do
St Richard's Hospital
The trust must ensure the monitoring of anaesthetic machine checks is recorded and aligns with best practice guidance.
Must Do
Royal Victoria Infirmary
The service must ensure systems and processes are established, operated, and audited effectively to ensure compliance with the requirement to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities.
Must Do
Royal Victoria Infirmary
The service must assess, monitor, and improve the quality and safety of the services and mitigate the risks relating to the health, safety and welfare of women, birthing people, and babies.
Must Do
Royal Victoria Infirmary
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks. This must ensure senior managers and the board members have clear oversight of service risks.
Must Do
Royal Victoria Infirmary
The service must operate effective systems and processes to make sure they assess and monitor their service. This should include the auditing of surgical safety checklists, documentation, infection prevention and control.
Must Do
Royal Victoria Infirmary
The service must ensure a robust audit plan is in place and key audits are conducted, which include record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted …
Must Do
Royal Victoria Infirmary
The service must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Royal Victoria Infirmary
The service must ensure clinical care and treatment are delivered and monitored in accordance with national guidance and best practice.
Must Do
Royal Victoria Infirmary
The service must ensure robust oversight and management of incidents and ensure incidents are shared across the health group.
Must Do
Royal Victoria Infirmary
The service must ensure there are clear processes and timescales for carrying out audit and re-audit of activities including the use of hospital passports in order to improve practice.
Must Do
Royal Victoria Infirmary
The service must implement an effective system to ensure incidents are appropriately reported to external systems within appropriate timescales.
Must Do
Royal Victoria Infirmary
Senior managers must ensure robust systems and processes are in place to identify, manage, mitigate and if appropriate escalate risks. This must ensure senior managers and the board members have clear oversight of service risks.
Must Do
Royal Victoria Infirmary
The service must monitor progress against plans to improve the quality and safety of services and take appropriate action without delay, where progress is not achieved as expected.
Must Do
Royal Victoria Infirmary
The service must operate effective systems and processes to make sure they assess and monitor their service. This should include the auditing of surgical safety checklists, documentation, infection prevention and control.
Must Do
Royal Victoria Infirmary
The service must ensure a robust audit plan is in place and key audits are conducted, which include record keeping, medicines management and infection prevention and control audits. The service must ensure relevant actions identified by local audits are acted …
Must Do
Royal Victoria Infirmary
The service must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Royal Victoria Infirmary
The service must improve its monitoring and auditing of surgical safety checklists and ensure the finding of these audits are shared with staff.
Must Do
Royal Victoria Infirmary
The service must ensure clinical care and treatment are delivered and monitored in accordance with national guidance and best practice.
Must Do
Royal Victoria Infirmary
The service must ensure all staff are engaged with and participate in all steps of the World Health Organisation (WHO) surgical safety checklist, the checklist is fully completed, and observational and record audits are undertaken to monitor compliance.
Must Do
Royal Victoria Infirmary
The service must ensure robust oversight and management of incidents and ensure incidents are shared across the health group.
Must Do
Royal Victoria Infirmary
The service must ensure there are clear processes and timescales for carrying out audit and re-audit of activities including the use of hospital passports in order to improve practice.
Must Do
Royal Victoria Infirmary
The service must have robust procedures in place for the identification, review and management of clinical risk when providing care and treatment.
Must Do
Royal Victoria Infirmary
The service must monitor progress against plans to improve the quality and safety of services and take appropriate action without delay where progress is not achieved as expected.
Must Do
Royal Victoria Infirmary
The service must ensure there are clearly defined assurance processes, including audits, and that all staff are aware of the required frequency and recording of these.
Must Do
Royal Victoria Infirmary
The service must assess, monitor, and improve the quality and safety of the services provided in the carrying on of the regulated activity.
Must Do
Royal Victoria Infirmary
The service must ensure systems and processes are established and operated effectively to assess, monitor and improve the quality and safety of the services provided in delivery of regulated activities, in line with national guidance and frameworks.
Must Do
Royal Victoria Infirmary
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
Royal Victoria Infirmary
The trust must ensure that high level risks are fully assessed and mitigated to the lowest level of risk.
Must Do
Royal Victoria Infirmary
The trust must ensure that risks recorded at corporate level and in the board assurance framework are current and have clear actions for mitigation which can be monitored and measured.
Must Do
Royal Victoria Infirmary
The trust must ensure it encourages the identification, reporting and investigation of incidents and risks in a timely fashion and shares learning to improve safety and quality of the service.
Must Do
Royal Sussex County Hospital
The trust should ensure they monitor staff compliance with high-risk pathways such as sepsis.
Should Do
Royal Sussex County Hospital
The trust should improve systems for monitoring induction compliance and oversight.
Should Do
Royal Sussex County Hospital
The trust must ensure improvements are made to governance systems and processes by conducting regular audits to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity. This includes auditing …
Must Do
Royal Sussex County Hospital
The trust must ensure hazardous waste such as sharps materials are managed and disposed safely in line with current legislation and guidance.
Must Do
Royal Sussex County Hospital
The trust must ensure equipment stored on wards does not inhibit cleaning in any way.
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(16)
An independent review of the Independent Investigations for Mental Health … — Rec 8
It is recommended that the IIGC should develop measures to demonstrate the impact and outcomes of the Independent Investigation process, with particular regard to; learning, service improvement, policy development and the experience of all affected families and carers.
north_west
An independent review of the Independent Investigations for Mental Health … — Rec 7
It is recommended that the IIGC should develop additional metrics and key performance indicators to provide assurance of regional adherence to quality as well as process requirements of Independent Investigations and the Serious Incident Framework.
north_west
An independent review of the Independent Investigations for Mental Health … — Rec 6
It is recommended that the IIGC should alert the National Quality Board and the Quality Assurance Group of the complexities and challenges of sharing learning and implementing improvement across the wider systems and with those partners identified by recommendation four.
north_west
An independent review of the Independent Investigations for Mental Health … — Rec 4
It is recommended that the IIGC continues to function as the strategic governance group for Independent Investigations into mental healthcare related homicides, and makes the necessary linkages with other national programmes of work i.e. mental health and quality and safety.
north_west
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1c
Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group to enable early identification of risk and timely intervention.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1b
A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly to provide a single, coordinated mechanism for monitoring and acting …
wales
Accepted
An independent review of the Independent Investigations for Mental Health … — Rec 9
It is recommended that the outcomes of the perpetrator characteristics and profile identified in this review be shared with the appropriate commissioners and service providers for the future commissioning of services.
north_west
An independent review of the Independent Investigations for Mental Health … — Rec 5
It is recommended that the IIGC identifies the strategic co-dependencies with agencies such as police, probation, prison engaged with mental health services to optimize the learning and improvement and to provide a platform for joint working at the strategic level.
north_west
An independent review of the Independent Investigations for Mental Health … — Rec 3
It is recommended that the requirement for consideration of predictability and preventability in IIMHH investigations is either removed or a national standard definition provided and used by all Investigation panels and included in the revision and the principles of the Serious Incident Framework.
north_west
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1d
A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bii
The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that its membership is expanded to include educators, researchers and student …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bi
We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on the national strategic oversight Board.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1a
The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, and provide strengthened clinical oversight and accountability of Health Boards …
wales
Accepted
An independent review of the Independent Investigations for Mental Health … — Rec 2
It is recommended that a national repository is provided to deliver a single access point for IIMHH reports, and that publication standards are developed to provide complete publication of the IIMHH, the synopsis and the recommendations for public access
north_west
An independent review of the Independent Investigations for Mental Health … — Rec 1
It is recommended that the process for Independent Investigations in Mental Health Homicides is reviewed in line with the review of the Serious Incident Framework. This process review should consider the proposals for: I. a single approach to the quality of reports; including standardised template and agreed investigation methodology II. …
north_west
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 2b
All maternity, neonatal and relevant education providers to actively progress through the stages of UNICEF UK Baby Friendly Initiative accreditation.
wales
Accepted
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
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