Poor health and social care integration
Lack of a fundamental shift towards collaborative, integrated system-wide change in health and social care.
Source spread
Where this theme appears
This theme appears across 24 independent accountability sources, so the source mix matters as much as the headline total.
70 inquiry recs
181 PFD reports
429 committee recs
58 HSSIB recs
49 CQC actions
2 HMICFRS recs
9 PPO recs
5 IOPC recs
27 NAO recs
1 PHSO rec
122 IMB recs
2 Scottish FAIs
10 Article 2 learning points
11 detention investigation recs
1432 DHR recs
97 PHSO decisions
390 LGO/SPSO decisions
1 CJINI report
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(70)— showing 50 strongest matches
26 — Recruit social workers with local authorities
Recommendation: A strong group of social workers should be recruited in association with the Local Authority Social Service Departments of Preston County Borough and Lancashire County and services built up along the lines set out in Chapter 7.
Unknown
25 — Single psychology department
Recommendation: Psychologists employed at the hospital should form one department and their work should be integrated into the therapeutic programme as a whole.
Unknown
19 — Co-ordinated psychiatric nursing division
Recommendation: The Chief Nursing Officer should become head of a co-ordinated psychiatric nursing division, including Ribchester, Sharoe Green and the future hospital department at Preston. The current reorganisation of nursing staff on Salmon Report lines should continue within this framework.
Unknown
17 — Professional Executive and therapeutic teams
Recommendation: The Group Secretary, the Chairman of the Medical Executive Committee and the Chief Nursing Officer, with other appropriate professional heads, should constitute a Professional Executive with delegated authority for day-to-day management of the hospital. They should maintain close liaison with …
Unknown
15 — Liaison with the Preston Group
Recommendation: The new Hospital Management Committee should maintain close liaison with the Preston Group to co-ordinate policy, particularly in relation to the admission unit at Sharoe Green and to plan a new service based on general hospitals at Preston and Chorley.
Unknown
11 — Reconstitute the Hospital Management Committee
Recommendation: The present members of the Hospital Management Committee should be invited to resign and the Committee reconstituted. In view of the pressing need to reorganise services at Whittingham, a small committee of about eight should be set up pending the …
Unknown
9 — Factors for the Board's reorganisation programme
Recommendation: The Board’s programme of reorganising mental illness services should emphasise factors which seem to us not to have been adequately recognised and are essential to the implementation of their policy: (i) the need to provide day places as well as …
Unknown
7 — Multi-disciplinary advisory panel for the Board
Recommendation: In the light of our findings we consider that the Board have suffered from a lack of advice from the field. The Board should establish a multi-disciplinary advisory panel containing comprehensive professional representation from the field to advise them on …
Unknown
6 — Co-operation between the Board and local authorities
Recommendation: We note the absence of local authority facilities in the Whittingham catchment area and consider that the Department should take steps to promote closer co-operation between the Regional Hospital Board and the local authorities concerned in planning the development of …
Unknown
1 — Guidance on long-stay elderly patients in the transition
Recommendation: The Department are, we understand, about to issue guidance on the problems of transition from mental illness services based on specialist psychiatric hospitals such as Whittingham to those based on units in general hospitals. Further thought and advice are urgently …
Unknown
162 — Consult before abandoning a case
Recommendation: Where a Reporter requires to consider the abandonment of a case which has been passed to the Sheriff for proof he should consult the Social Work Department before finally deciding to do so (18.50).
Unknown
161 — Local guidelines on information to Reporter
Recommendation: It should be clearly stated in all local guidelines in what form if any information requires to be given to the Reporter (18.48-49).
Unknown
119 — Agreed strategy for joint interviews
Recommendation: Where agencies are to undertake joint interviews, there should be an agreed strategy both for the course of interviews and for the resolution of disputes and for the assessment of the ongoing work both by managers and interviewers (17.59).
Unknown
78 — Mutual understanding between authorities
Recommendation: Where a child is placed outside the area of the child’s own local authority the Social Work Departments of the two areas should have a clear mutual understanding of the roles and responsibilities of those involved in the care of …
Unknown
31 — National guidance on inter-area co-operation
Recommendation: The national guidance should include guidance on the principles to be followed where authorities or agencies of different areas require to co-operate in dealing with complex cases of child abuse together with other particular matters suggested in the main Report …
Unknown
30 — Co-operative preparation of national guidance
Recommendation: The national guidance should be prepared with the co-operation of all agencies and disciplines engaged in work in the field of child abuse and be available as guidance for all of them (15.61). It should include guidance on all forms …
Unknown
21 — Cooperation between two local authorities
Recommendation: Where two separate local authorities become involved in the investigation of a case of suspected multiple sexual abuse which extends over both their areas the heads of the respective agencies involved should make special arrangements to ensure complete co-operation (15.47).
Unknown
15 — Schools to link with Social Work Departments
Recommendation: The discovery of sexual abuse is not the monopoly of any agency. In particular, schools should establish close links with their local Social Work Departments. Teachers should be designated to be trained in the recognition of child sexual abuse and …
Unknown
14 — Joint training and joint guidelines
Recommendation: To assist in practical co-operation both agencies should engage in joint training and should prepare joint guidelines (15.33).
Unknown
13 — Designated senior coordinator in multiple abuse
Recommendation: At least in cases of suspected multiple sexual abuse a senior member of the staffs of the Police and Social Work Department should be designated to co-ordinate their joint work (15.32).
Unknown
12 — Agencies share information in joint approach
Recommendation: In a joint approach while investigation of a case is properly a matter for the police each agency should share fully with each other the whole information relevant to their particular responsibilities (15.30-31).
Unknown
R101 — Whole-system commissioning with cross-agency risk assessment
Recommendation: Planning and commissioning services for people with learning disabilities and autistic people should be done as a single process across the whole system (including primary care, housing, benefits and independent and third sector providers of services). There must be a …
No response yet
R94 — Continuing community support provision
Recommendation: There will be a continuing need, which must be met, for new and ongoing community-based support for young people and adults with learning disabilities and autistic people whose families become unable to cope full time. This means there is a …
No response yet
191 — Accessible social workers
Recommendation: Social workers should be readily accessible and available to the particular community which they serve and know and be known by it (19.28).
Unknown
163 — Reporter and Procurator Fiscal to consult
Recommendation: The Reporter and the Procurator Fiscal should consult together to avoid conflict between the courses of action to be taken and they should also be invited to attend case conferences where appropriate (18.51).
Unknown
20 — Independent professional advice for Social Work Departments
Recommendation: Social Work Departments should have recourse to independent professional advice in all appropriate cases in addition to the carrying out of any necessary medical examinations. A list of persons suitably skilled and experienced in providing such advice should be available …
Unknown
19 — Early inter-disciplinary meeting and parental involvement
Recommendation: In any case of child sexual abuse an inter-disciplinary meeting should be held at the earliest stage (15.39). Parents should usually be informed from the outset that the suspicion exists and that the matter is being investigated. Their co-operation should …
Unknown
194 — Orkney Islands Council and the community
Recommendation: Orkney Islands Council should take active steps towards improving the relationship between themselves and in particular their Social Work Department and the local community (19.33).
Unknown
180 — Joint training with other agencies
Recommendation: Joint training should be undertaken between the social work profession and other agencies including in particular the police (19.15).
Unknown
164 — Police duty to inform Reporter
Recommendation: In all cases where a police constable has reasonable cause to believe that a child may be in need of compulsory measures of care he should be under a statutory duty to pass that information to the Reporter (18.52).
Unknown
157 — Reporters not to investigate
Recommendation: It is not recommended that Reporters should undertake an investigative function before matters are brought formally to their attention (18.43).
Unknown
136 — SWSG to prepare interviewing guidelines
Recommendation: As part of the national guidance already recommended SWSG should undertake the preparation of guidelines for the investigative interviewing of children in consultation with representatives of all the agencies and professions who may be involved in that work (17.78).
Unknown
134 — Review before departing from interview plan
Recommendation: Any departure from the purpose or number of interviews should only be made after a full review of the situation and the agreement of all agencies (17.76).
Unknown
128 — Planned supervision of joint interviews
Recommendation: Where interviews are being undertaken jointly, supervision should be planned on an occasional but regular joint basis (17.70).
Unknown
16 — Awareness for school administrative bodies
Recommendation: The administrative bodies of all schools should be helped to develop an awareness of the problems involved in child sexual abuse and the roles of the various agencies engaged in dealing with it (15.36).
Unknown
53 — Timing of first review of assessment
Recommendation: The first review of the initial assessment should take place within one week of the initial assessment, and should take place in every case. It should be a multi-disciplinary review, with representatives from the prisoner’s wing, healthcare and the team …
Unknown
R10 — Access to allied health professionals
Recommendation: It is critical for the wellbeing of people with learning disabilities and autistic people that they are well supported by, and have access to, AHPs including psychologists, speech and language therapists (SALTs), occupational therapists (OTs), podiatrists and dieticians. These AHPs …
No response yet
RHI-18 — Inter-Governmental Framework
Recommendation: More generally, we recommend a Northern Ireland government-wide framework for information exchange and, where appropriate, co-operation between the Northern Ireland Civil Service, Whitehall Departments and (where relevant) Departments of other devolved Governments and of the Government of the Republic of …
Gov response: These recommendations can be accepted in full. They have been addressed in work to date through: • initial steps to establish a project delivery profession which will, once in place, take forward the recommended programme …
Accepted
29 — Split the inner catchment area into districts
Recommendation: The inner catchment area of Whittingham Hospital coincides with that of the Preston Group. This should be split into defined districts, each with the responsibility of a single multi-disciplinary therapeutic team.
Unknown
27 — Co-ordinate occupational services
Recommendation: All occupational services, including industrial therapy, should be effectively co-ordinated under the aegis of a professional Resocialisation Group. They should be expanded, with the emphasis on industrial therapy, to provide activities for all patients who can make use of them.
Unknown
20 — Nurse training in co-ordination with Sharoe Green
Recommendation: Training for student and pupil nurses and experience of trained staff should be arranged in co-ordination with Sharoe Green and the new Preston hospital facilities to give adequate variety in all types of patient care.
Unknown
16 — Medical Executive Committee
Recommendation: The senior medical staff with clinical sessions at the hospital, together with representatives of other medical staff, should constitute a Medical Executive Committee, electing a Chairman whose appointment should be subject to yearly renewal. The Chief Nursing Officer and other …
Unknown
156 — Reporter's independence in discussions
Recommendation: In any informal discussion between the Social Work Department and the Reporter his independence of action must be recognised and respected (18.39-41).
Unknown
117 — Channels from interviewers to case managers
Recommendation: Clear communication channels should be set up from interviewers to case managers (17.57).
Unknown
18 — Joint MoJ/DfE policy for children in custody
Recommendation: The Chair and Panel recommend that the Ministry of Justice and the Department for Education share policy responsibility for managing and safeguarding children in custodial institutions. This is to ensure that standards applied in relation to children in custody are …
No response yet
R91 — Higher-funded resettlement team for complex needs
Recommendation: There needs to be a recognition that those service users in Northern Ireland yet to be resettled (if there are any by the time of publication of this report) will require a higher level of funding due to their needs …
No response yet
IHRD-49 — Multi-Trust Mortality Meeting Engagement
Recommendation: Where the care and treatment under review at a mortality meeting involves more than one hospital or Trust, video conferencing facilities should be provided and relevant professionals from all relevant organisations should, in so far as is practicable, engage with …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F235 — Joint proceedings
Recommendation: The Professional Standards Authority for Health and Social Care (PSA) (formerly the Council for Healthcare Regulatory Excellence), together with the regulators under its supervision, should seek to devise procedures for dealing consistently and in the public interest with cases arising …
Gov response: Accepted in part. The Professional Standards Authority oversees the work of the professional regulators, but it has no powers to intervene directly in cases (save that where it considers the outcome of a fitness to …
Accepted in part
F234 — Cooperation with the Care Quality Commission
Recommendation: Both the General Medical Council and Nursing and Midwifery Council must develop closer working relationships with the Care Quality Commission – in many cases there should be joint working to minimise the time taken to resolve issues and maximise the …
Gov response: Accepted. The General Medical Council has been working closely with the Care Quality Commission to build on its Memorandum of Understanding. Similar close joint working has also started with the Nursing and Midwifery Council. The …
Accepted
SP53 — GMMH and Alder Hey joint SMART audit
Recommendation: At the local level, Greater Manchester Mental Health NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust should by no later than 13 October 2026 carry out and report on a joint audit to ensure that for cases involving …
Gov response: DHSC has limited powers to direct NHS Foundation Trusts to implement recommendations 51 and 53. The Secretary of State for Health and Social Care has written to Greater Manchester Mental Health NHS Foundation Trust and …
Accepted
Prevention of Future Deaths reports(181)— showing 50 strongest matches
Karen Sutton
Concerns: The immunology team was not notified of the patient's hospital admissions, preventing their input into care and discharge. The patient was also discharged without prophylactic antibiotic medication due to a lack of a Trust-wide policy for inter-departmental admission sharing.
Response (University Hospitals of Leicester): • The Medical Director wrote to all Consultants to remind them of their duty to contact specialist teams for complex patients. • The Trust expects to implement software by April … (AI summary)
Responded
Rose Jean Coles
Concerns: The coroner identified insufficient communication between the neonatal intensive care unit and the cardiac unit, which was considered unsuited for premature babies, indicating a need for improved protocols or checklists.
Response (University Hospital Bristol): • The Trust provided a composite action plan addressing the matters of concern. • The Trust stated many actions described within the plan were already in hand. • The Trust … (AI summary)
Responded
Michael Longley
Concerns: The coroner noted difficulties for Integrated Care 24 in contacting the District Nursing Service, indicating a need for improved oral and written communication methods between IC24 and district nurses.
Overdue
Leslie Pates
Concerns: The coroner noted insufficient communication between the hospital, social services, and the family regarding the patient's discharge plan. Concerns were also raised about the patient being discharged home with severe pressure sores and no pressure-relieving mattress.
Response (Tamside Hospital NHS): • The Trust implemented a checklist and monitoring systems to enhance communication and ensure documented engagement between multidisciplinary teams, patients, and families regarding discharge plans. • Processes were established for … (AI summary)
Overdue
Peter Galea
Concerns: The coroner noted limited mechanisms for agencies to break the cycle of referrals to allow for more detailed mental health assessments, and expressed concern about limitations on GPs directly admitting patients to a place of safety.
Overdue
Lorna Cullen
Concerns: The coroner noted concerns regarding long waiting times for mental health assessments in hospital emergency departments, attributed to insufficient liaison psychiatry nurse staffing levels. The key issue identified was the long-term sustainability of adequate staffing after temporary funding for increased resources was set to expire.
Overdue
Jamie Barlow
Concerns: The coroner identified a need for improved inter-agency working and clearer communication when police assistance is sought for mental health assessments. This includes reviewing current processes and considering an inter-agency protocol for joint management of assessments where risk is perceived.
Overdue
Stephen Church
Concerns: The British Transport Police experienced a broken chain of command, and staff from the psychiatric liaison service and Royal Berkshire Hospital had insufficient knowledge of interagency protocols. This contributed to a lack of joint working and delays in arranging a Mental Health Act assessment.
Response (Thames Valley Police): • A new draft of the interagency protocol for managing mental health in the Thames Area is in the consultation phase and will incorporate inquest findings. • Thames Valley Police … (AI summary)
Response (British Transport Police): • The British Transport Police (BTP) stated it would implement recommendations from an ongoing Independent Police Complaints Commission investigation into the breakdown of the command chain. • BTP updated its … (AI summary)
Response (Royal Berkshire NHS Trust1): • An interagency meeting was held to discuss concerns regarding mental health protocols and interagency working. • A flowchart for A&E staff was drafted, finalised, and approved to clarify steps … (AI summary)
Responded
Neophytos Constantinou
Concerns: The coroner noted a lack of clarity in procedures for arranging transportation for patients with complex medical issues, which could lead to necessary medical procedures being missed due to administrative issues.
Overdue
Pauline Taylor
Concerns: Insufficient precision in the surgical term 'nephroureterectomy' led to clinician misunderstanding of the procedure's extent. Additionally, there was no designated case manager to monitor the patient's progress and coordinate care in a complex case.
Response (Department of Health): • Department of Health officials liaised with the British Association of Urological Surgeons (BAUS) to clarify the term "nephroureterectomy". • The Department reported that BAUS defined "nephroureterectomy" as the removal … (AI summary)
Response (Leeds Teaching Hospital): • The Trust sought and received clarification on the surgical term "nephroureterectomy" from the British Association of Urological Surgeons, subsequently emphasising this guidance to relevant staff and arranging its inclusion … (AI summary)
Responded
Louise Henry
Concerns: The coroner identified a misunderstanding between the CMHT and the DCC Recovery Team regarding the latter's adherence to the Care Programme Approach (CPA) and the roles of its lead professionals as care co-ordinators. This led to a lack of clarity concerning responsibilities and service frameworks.
Response (Derbyshire Healthcare NHS Trust): • The Council and Derbyshire Healthcare NHS Trust stated they would review roles and responsibilities at a Service Manager Interface Meeting. • A plan was agreed to update the Derbyshire … (AI summary)
Response (NHS England): • A reminder was issued to practices regarding the use of Special Patient Notes and Right Care Plans for patients with mental health conditions. • Practices were recommended to review … (AI summary)
Responded
Shannon Gee
Concerns: The coroner identified delays in resolving clinical disputes between organisations due to differing treatment thresholds, which created a gap in service provision. Difficulties with the transfer of medical notes and records were also noted.
Overdue
George Taylor
Concerns: The coroner noted the undesirable practice of sending 8 to 12 psychiatric patients out of county monthly due to a lack of acute beds, identifying a risk that this could lead to a future death.
Response (Department of Health): • The Minister made NHS England aware of the report. (AI summary)
Response (NHS Kernow Clinical Commissioning Group): • NHS Kernow commissions 54 acute mental health assessment and treatment beds and has a contract with Cygnet Hospitals for additional specialist beds. • It is working with partners to … (AI summary)
Responded
Andrew Frost
Concerns: The coroner noted a lack of shared understanding between general practitioners and the Islington Crisis Team regarding the team's capacity and whether it functions as an emergency service, recommending specific training for GPs on crisis team limitations.
Response (Killick Street Health Centre): • Killick Street Health Centre met with the Crisis Team on 19 March to discuss service provision. • The Health Centre decided to meet with the Crisis Team on a … (AI summary)
Responded
Robert Yarnell
Concerns: The coroner identified a lack of proactive contact and follow-up by the care team after Mr Yarnell's discharge and relocation, including failing to make home visits or use known family contact details, resulting in a six-week gap in care.
Overdue
Alexander Ball
Concerns: The coroner identified a lack of communication between the Trust and other agencies, exacerbated by the absence of a dedicated Care Co-ordinator for patients with complex needs.
Response (Greater Manchester West NHS Trust): • Unity is actively involved in the Cumbria wide Crisis Care Concordat working group and is a member of Frequent Attenders meetings to provide a joined-up approach for complex patients. … (AI summary)
Response (Cumbria Partnership): • The Trust stated it would facilitate an Oxford Learning Event with partner agencies to address communication issues for clients with mental health and substance misuse problems. • The Trust … (AI summary)
Responded
Andrew Nickolls
Concerns: The report identifies a need for prompt and clear information sharing between healthcare providers for vulnerable adults whose primary care is outside their local Clinical Commissioning Group area. It also suggests sharing such information with police.
Overdue
Meryl Parry
Concerns: The coroner notes an absence of a system requiring residential home managers to seek advice from Social Services before discharging residents, raising concerns about ensuring resident safety and welfare after discharge.
Response (Greenlane Care Homes Limited): • Greenlane Care Homes Limited confirmed that its Discharge Pack had been changed. • The updated Discharge Pack now includes the procedure for unanticipated discharges. (AI summary)
Overdue
Alun Walters
Concerns: The practice lacked software for prescription decisions, a system for notifying missed INR tests, and failed to maintain an anti-coagulation register. Additionally, the coroner noted a failure to inform the pharmacy of Warfarin withdrawal when INR safety testing was not conducted.
Overdue
Mary James
Concerns: The coroner noted inadequate monitoring of INR levels and uncertainty regarding Warfarin adherence for a patient with dementia. There were also concerns about communication gaps between the INR Unit, care home, and GP, and a missed opportunity for hospital admission to adjust anticoagulation therapy.
Overdue
Samantha Beach
Concerns: The coroner noted a lack of appropriate escalation of clinical care in the obstetric department and insufficient processes for information sharing and coordinated care between various community and hospital services for post-natal patients.
Overdue
Margaret Ferry
Concerns: The coroner identified a lack of policy clarifying responsibilities and communication channels between Sunderland and County Durham and Darlington NHS Trusts for patient referrals. There were also poor communication levels and a poor understanding of differing practices between medical professionals at the two trusts.
Response: • The Trusts developed a new standing operational procedure for inter-organisational referrals for plastic surgery opinions. • The procedure clarifies documentation, response timescales, and patient care responsibilities during referrals. (AI summary)
Responded
Barry Thraves
Concerns: The report identifies significant delays in psychiatric follow-up appointments and a lack of planned community support, compounded by poor communication between mental health teams and other stakeholders. Insufficient information was provided to the patient and family regarding care teams and contact points.
Response: • The council developed a new process, effective January 2016, to ensure individuals and identified carers receive written information about assessment delays, including contact details and available support services. • … (AI summary)
Response: • Community mental health team staff were reminded of the requirements of the Did Not Attend (DNA) policy and their duty to follow it. • The Trust is reviewing its … (AI summary)
Responded
Charlotte Bevan and Zaani Malbrouck
Concerns: The coroner noted a lack of evidence that multi-disciplinary team meetings are consistently held or that comprehensive, widely-circulated care plans are consistently developed for pregnant individuals with known mental health conditions.
Response: • Dr Kathryn Bundle has been tasked to review perinatal pathway arrangements against NICE guidelines, with draft algorithms developed and being consulted on. • The Trust plans to prepare and … (AI summary)
Responded
Jacqueline Williams
Concerns: The coroner noted insufficient systems for mental health referrals, allowing human error to go undetected. Emergency department staff could not confirm referral acceptance, nor could the Mental Health Liaison Team identify patients awaiting assessment.
Response (Lancashire Care NHS Trust): • Staff were briefed on the referral process, and learning from a joint investigation was shared. • The Trust met with East Lancashire Teaching Hospitals NHS Trust to explore improvements … (AI summary)
Responded
Colin Williams
Concerns: The coroner expressed concern that individuals with complex needs and variable mental capacity faced significant difficulty navigating multiple agencies and understanding service funding. This "agency blindness" prevented access to support, compounded by changes in funding models and complex paperwork requirements.
Overdue
Louise Locke
Concerns: The coroner identified concerns regarding a premature discharge from the Community Mental Health Service without adequate risk assessment or support, and the lack of a system to collate information from other agencies. The report also highlights the absence of a consistent multi-agency approach to high-risk individuals and suicide prevention across all areas served by Southern Health.
Response (Southern Health NHS Foundation Trust): • Clinical Service Directors will formulate a standard plan to ensure patients requesting second opinions are not prematurely discharged. • The Standard Operating Procedure for patients attending Emergency Departments for … (AI summary)
Responded
Isla Lord
Concerns: The coroner noted a lack of liaison between University College Hospital and Princess Alexandra Hospital to formulate an agreed delivery plan for a baby with identified heart anomalies. There is a need to review the system between tertiary and local hospitals for these cases.
Response (I lord): • The Standard Operating Policy for obstetric ultrasound scanning was amended to require consultants to request and document detailed delivery plans for patients referred to tertiary centres. • The amended … (AI summary)
Responded
Philip Denning
Concerns: The coroner identified fragmented service provision for patients with co-occurring substance misuse and mental health issues, with insufficient information sharing and joint working between providers. There is also a lack of understanding in primary care about accessing appropriate help.
Overdue
Leslie Morrison
Concerns: The coroner raised concerns about the lack of formal mental capacity assessment and DoLS consideration both in the community and upon hospital admission. There was also insufficient communication between care providers, resulting in crucial patient information not being shared with the hospital.
Response (MORRISON Leslie): • The Trust stated it would implement a Trustwide initiative to develop a policy or pathway for proactively gathering information for complex and vulnerable patients. • The Trust is piloting … (AI summary)
Overdue
Winston Harris
Concerns: The care plan for Mr Harris did not address his absconding risk, and this critical information was not effectively transferred to the hospital. Additionally, the hospital did not consider an emergency Deprivation of Liberty Safeguards (DOLS) application, and the DOLS application itself experienced significant processing delays.
Response (Birmingham City Council): • The council has invested efforts and resources to reduce the Deprivation of Liberty Safeguards (DOLS) assessment waiting list. • Plans are in place to ensure future DOLS applications are … (AI summary)
Response (Sandwell and West Birmingham NHS Trust): • The Trust confirmed its policies and procedures are in place and available, and has conducted workshops and strengthened safeguarding training for staff. • It is developing an aide memoire … (AI summary)
Responded
Patrick Steer
Concerns: Concerns were raised regarding inadequate communication between Surgical and Coronary Care teams for patients under shared care, and the absence of a clear Trust policy to manage this interaction.
Responded
Christopher MacMorland
Concerns: The coroner noted concerns that Mr MacMorland was not transferred to a specialist gastroenterology ward despite five consultant requests, potentially affecting his outcome. It was also noted that consultants' requests for patient transfer to specialist wards are commonly not implemented.
Response (Portsmouth Hospitals NHS Trust): • The Hospital has implemented a 'buddy' ward system. • This system ensures patients of a specific specialty are cohorted into appropriate specialist or designated buddy wards. • Consultants' patients … (AI summary)
Responded
Grant Burns
Concerns: The coroner noted a lack of co-operative working and communication between the Early Intervention in Psychosis Service and the Substance Misuse Service, which also led to an incomplete Root Cause Analysis report.
Response (Solent NHS Trust): • A spreadsheet of clients involved with both Adult Mental Health and Substance Misuse Services was compiled and added to weekly and twice-weekly meeting agendas. • New processes were established … (AI summary)
Responded
Kymberley Holden
Concerns: The coroner noted ongoing risks from unsafe prescribing of controlled drugs by Ivy Grove Surgery and a limited understanding of reporting serious prescribing incidents. Concerns were also raised about poorly coordinated management and prescribing for neurological patients under shared care.
Overdue
Christiana Pelle
Concerns: The coroner noted a lack of clear guidance for community district nurses on GP involvement and insufficient systems for sharing information or escalating concerns among various partner agencies and care providers involved in community patient care.
Overdue
Jonathan Zucker
Concerns: The coroner identified the absence of a requirement or system for a lead clinician to oversee and coordinate Mr. Zucker's care, which was provided by both private and NHS mental health services.
Response (PSYCH): • The Royal College of Psychiatrists stated that its Professional Practice and Ethics Committee would consider issues related to consultant accountability, ownership during transitions, and care involving multiple teams. • … (AI summary)
Response (Department of Health): • Department of Health officials liaised with the Royal College of Psychiatrists regarding the concerns raised. • The Royal College of Psychiatrists intends to ask its Professional Practice and Ethics … (AI summary)
Responded
Lee Swain
Concerns: The coroner identified a lack of co-ordinated mental health service transfers between NHS Trusts, as removing a user from the Care Programme Approach led to GP-mediated referrals, delaying intervention and hindering information exchange.
Overdue
Margaret Conway
Concerns: The coroner notes that Acute Medical Wards and Mental Health Services are geographically and operationally separate, making transfers of patients with co-occurring serious mental and physical health problems challenging. Improved integrated working, clear pathways, and shared resources are needed to enhance care.
Overdue
Beryl Varcoe
Concerns: The coroner notes that an installer's practice of only range testing community alarms in regularly used areas means many existing alarms may not function throughout clients' homes. This raises concerns for service-users whose alarms were fitted before new comprehensive testing procedures were introduced.
Overdue
Sharon Halliwell
Concerns: The Trust had not fully addressed the issue of connectivity, despite other issues raised in evidence having been addressed.
Response (North West Boroughs Healthcare NHS Trust): • The Trust shared a "theme of the week" communication and provided RiO training to IAPT staff. • A 'flag' system for RiO and IAPTUS records is being developed for … (AI summary)
Responded
Andrew Reid
Concerns: The coroner noted a disparity in urgent mental health service provision across Greater Manchester, specifically that Trafford's Home Based Treatment Team does not accept direct GP referrals, unlike Manchester's. This meant GPs dealing with urgent mental health issues for Trafford residents out-of-hours had to ask patients to attend A&E.
Response (Andrew REID): • GMMH managers reminded teams of their responsibilities for service user care and the use of the Cross Border Matrix. • Trafford CCG and MHCC agreed with GMMH to escalate … (AI summary)
Response (Andrew REID Response2): • An agreement was made for disputed referrals between teams to be promptly escalated to a Service Manager. • Service managers reminded teams of their responsibilities to ensure service users … (AI summary)
Responded
Barbara Ellis
Concerns: The coroner noted difficulties in cross-border care provision where a patient's GP and social care commissioning are in different counties, leading to an inability to access therapeutic services.
Overdue
Sufia Begum
Concerns: The coroner notes that not all doctors were aware of the BNF mobile device APP, which is a useful tool for identifying potential drug interactions.
Response (Sufia Begum Response2): • NHS England distributed learning about the case across all West Midlands CCGs and Providers. • Sandwell and West Birmingham Hospitals NHS Trust issued trust-wide communications and emails to staff, … (AI summary)
Response (Sufia Begum): • The CCG contacted Sandwell and West Birmingham Hospitals Trust to seek assurance regarding actions to prevent reoccurrence. • The CCG wrote to contracted NHS providers and primary care providers … (AI summary)
Responded
Paul Allan
Concerns: The coroner noted that the Rochdale Community Mental Health Team discharged the patient instead of transferring him to the Stoke team upon his move, and did not consult with alcohol advisory services as required.
Response (Pennine Care NHS Trust): • The Trust will circulate a reminder to staff regarding the Care Programme Approach (CPA) policy and has included CPA on its 2018/19 clinical audit programme. • The Trust secured … (AI summary)
Responded
David Stacey
Concerns: The coroner identifies the lack of an identifiable facility for mentally disordered patients requiring special urgency beds in Leicestershire, a statutory requirement under the Mental Health Act 1983. This appears to be ignored, risking future similar situations.
Response (the Department of Health and Social Care): • The Department is preparing a report to support Clinical Commissioning Groups and local authorities in improving the implementation of requirements under section 140 of the Mental Health Act. • … (AI summary)
Overdue
Robin McEwan
Concerns: The coroner identified a lack of direct communication between private therapy and the GP regarding the patient's welfare, and insufficient exploration of potential family support when professional help was not immediately available.
Response (Harrogate CCG): • The CCG will review the referral process for private counselling services to ensure GPs are informed of patient progress. • The CCG will review and further develop its website … (AI summary)
Responded
Brian Frost
Concerns: The coroner raised concerns about unsafe loose kitchen floor tiles acting as a trip hazard for a frail resident. Welfare visits by the diocese did not include health and safety or risk assessments, despite the resident's known frailty and history of falls, indicating a broader risk for other 'grace and favour' residents.
Overdue
Charles Grainger
Concerns: The coroner noted that relevant information regarding Mr Grainger's falls history could not be shared between agencies due to system limitations, hindering cohesive multi-agency working. This led to a failure to properly request, review, and retain copies of falls risk assessments.
Overdue
Canon Frost
Concerns: Welfare visits to retired priests in 'grace and favour' properties did not include health and safety or risk assessments, even when residents had a history of falls and mobility issues. This meant significant trip hazards, such as loose floor tiles, were not identified or addressed in the deceased's home.
Response: • The Diocese has reviewed its procedures for supporting retired priests living in diocesan accommodation. • Annual welfare visits will now include a Diocesan Surveyor to conduct full external and … (AI summary)
Overdue
Select committee recommendations(429)— showing 50 strongest matches
#29 —
Recommendation: Following the interim findings of the NHS England review, and by no later than April 2024, the Government should establish and fund an independent review into the homecare system. This review must not delay the enactment of those measures which …
Response attribution not verified
#183 —
Recommendation: Rebecca Robson told us that probation staff are based in her organisation âone or two days a weekâ, and thanks to this âinformation sharing works really well, including about the ongoing riskâ. 349 She explained that âin Cumbria, it is …
Response attribution not verified
#170 —
Recommendation: Niki Scordi told us that the commissioning process in 2021 was a considerable improvement on the previous process five years earlier. She talked about âmassive improvementsâ, and specifically welcomed the commissioning of âa holistic serviceâ for women, allowing organisations like …
Response attribution not verified
#164 —
Recommendation: Community sentences are more effective when the Probation Service is a fully engaged member of local partnerships, be it through the co-location of services or through cooperation forums, allowing information to circulate. This benefits offenders and there is also a …
Response attribution not verified
#162 —
Recommendation: The APCC pushed for more communication among local agencies. They told us about Drug Rehabilitation Requirements and âthe example of an offender who needs to be tested twice a weekâ: âProbation and Police should be notified of every test; if …
Response attribution not verified
#161 —
Recommendation: While we heard about best practices in the local delivery of probation services, we were also told that communication may be difficult among the various local agencies involved in the delivery of community sentences. Justin Russell, for instance, told us …
Response attribution not verified
#160 —
Recommendation: We also heard about Integrated Offender Management (IOM), which the Government defines as âa cross-agency response to the crime and reoffending threats faced by local communitiesâ. 295 Pavan Dhaliwal told us that IOM provides a âgood exampleâ of âwhere the …
Response attribution not verified
#156 —
Recommendation: They told us that co-commissioning benefits users as well as providers. They explained that âthe benefit of this approach is the person accessing these services can stay engaged with them as long as their need dictates rather [than] just while …
Response attribution not verified
#155 —
Recommendation: The Greater Manchester Combined Authority (see Box 6) told us about co-commissioning, where the same services are âsupported by a range of local commissioners which may include health, local authority, adult learning and skills etc, as well as criminal justiceâ …
Response attribution not verified
#154 —
Recommendation: Co-commissioning and co-location were also recognised as best practice. Dr Abramovaite said: âto have all the services sitting together as a multidisciplinary team trying to assess and help individuals in the best possible way is definitely very much needed.â 286 …
Response attribution not verified
#152 —
Recommendation: We heard about best practices in Northern Ireland. The Probation Board of Northern Ireland (PBNI) told us that Enhanced Combination Orders involve âa multiagency, multidisciplinary, collaborative approach, with PBNI leading on the Order, and support provided by a range of …
Response attribution not verified
#151 —
Recommendation: We heard that the Probation Service âneeds the local empowerment and local multiagency links that can make a difference for the people they are supervisingâ. 279 Justin Russell told us that âregional directors would welcome more devolution, and more power …
Response attribution not verified
#150 —
Recommendation: Much of the evidence we received related to how the Probation Service cooperates with local agencies, such as local teams of the Probation Service and of the Prison Service, the Police, the NHS, local authorities, and their contracted partners. NAPO …
Response attribution not verified
#133 —
Recommendation: Best practice was also identified in âproperly embedded multi-agency workingâ and âthe range of local services that youth offending services have a connection toâ. 251 Kim Thornden-Edwards explained that âyouth offending services are very networked into services for young peopleâ …
Response attribution not verified
#129 —
Recommendation: Over the course of our inquiry, we were told about a range of best practices in the delivery of probation services across England and Wales. In this chapter, we consider how they could be scaled up. We look at the …
Response attribution not verified
#121 —
Recommendation: We also heard that âthe greater use of appropriate and well-supervised out of court disposals is an option in that areaâ. 237 Phil Bowen told us about a service in Highbury Corner Magistratesâ Court provided by the Centre for Justice …
Response attribution not verified
#116 —
Recommendation: However, Dr Guilfoyle cautioned that the integrated CSO, first piloted in 2016, âhas not been hugely effectiveâ. He told us that it may be because âwhen it first became operational the individuals themselves had to source the training or treatment …
Response attribution not verified
#110 —
Recommendation: Justin Russell said that to reduce the criminal activity of low-level, âprolificâ offenders, their rehabilitation âwould need to involve a residential elementâ and âtreatment for mental health and/or drug and alcohol problemsâ, which âwould probably need to involve someone consentingâ …
Response attribution not verified
#106 —
Recommendation: The then Chief Inspector of Probation told us about a âgap in the market for people with very profound needs who commit very prolific low-level offending but are probably not being reached by community sentences at the momentâ. 196 He …
Response attribution not verified
#105 —
Recommendation: Witnesses told us about the âmultiple and complex needsâ of âprolificâ offenders. 193 For instance, Rebecca Robson told us that âmental health problems are very common in what we call prolific offenders, together with poor experiences of the education system …
Response attribution not verified
#104 —
Recommendation: The Government should provide additional funding for the various rehabilitative services provided by womenâs centres and explore options for wraparound support to be made available to all people who would benefit from it, giving them the best opportunity to stop …
Response attribution not verified
#103 —
Recommendation: We note that the Ministry of Justice shares these concerns and has commissioned some specialised womenâs services. This model, in which offenders receive tailored, wraparound rehabilitative support from a single provider in a single location, is proving effectiveâ it is …
Response attribution not verified
#102 —
Recommendation: Women entering the Criminal Justice System in England and Wales are often the victims of abuse and discrimination, or suffering from trauma, addiction, and mental health issues. Many of them have caring responsibilities. These issues, acknowledged by the Government in …
Response attribution not verified
#101 —
Recommendation: In the same spirit, the Greater Manchester Combined Authority told us that after a 12-month pilot, âwe have recently commissioned Well-being services which are predominantly focused on supporting the needs of men, adapting many of the principles and learning from …
Response attribution not verified
#100 —
Recommendation: The question was raised of how male offenders could benefit from this practice. Carrie Peters, Director of Justice Services at Ingeus, told us that âwe need menâs services to be commissioned in a holistic way by region in the same …
Response attribution not verified
#87 —
Recommendation: Chief Probation Officer Kim Thornden-Edwards told us about âa new national partnership agreement on health and social careâ, agreed in February 2023. This new partnership, between the Ministry of Justice and the Department of Health and Social Care, âfunds some …
Response attribution not verified
#86 —
Recommendation: To enact such changes, witnesses told us about the âCommunity Sentence Treatment Requirement (CSTR) protocolâ between the Ministry of Justice and HMPPS, on the one hand, and NHS England and Public Health England, on the other hand. 164 The protocol …
Response attribution not verified
#78 —
Recommendation: Pavan Dhaliwal, Chief Executive of Revolving Doors, alluded to âcombined ordersâ, involving more than one treatment requirement. 135 Caroline told us that she âhad the mental health treatmentâ and âjust needed that Alcohol Treatment Requirement (ATR) as wellâ, emphasising the …
Response attribution not verified
#29 —
Recommendation: We encourage the Probation Service to empower regional directors further, ensuring that a greater proportion of rehabilitative services are commissioned locally. They should be granted further autonomy to develop partnerships with local organisations and public agencies. Co-commissioning should be encouraged. …
Response attribution not verified
#28 —
Recommendation: Community sentences are more effective when the Probation Service is a fully engaged member of local partnerships, be it through the co-location of services or through cooperation forums, allowing information to circulate. This benefits offenders and there is also a …
Response attribution not verified
#17 —
Recommendation: The Government should provide additional funding for the various rehabilitative services provided by womenâs centres and explore options for wraparound support to be made available to all people who would benefit from it, giving them the best opportunity to stop …
Response attribution not verified
#16 —
Recommendation: We note that the Ministry of Justice shares these concerns and has commissioned some specialised womenâs services. This model, in which offenders receive tailored, wraparound rehabilitative support from a single provider in a single location, is proving effectiveâit is dignified, …
Response attribution not verified
#13 —
Recommendation: A greater proportion of people on probation should be served one or more treatment requirement(s). This could be achieved by implementing our recommendations on Pre-Sentence Reports (see paragraphs 255â259) and on âintegratedâ sentences (see paragraphs 123â127), and through a greater …
Response attribution not verified
#12 —
Recommendation: Many people on probation suffer from mental health issues and from addiction to alcohol or drugs, which fuels their offending behaviour. Few of them are referred to a Community Sentence Treatment Requirement (CSTR). And yet, referrals exceed the availability of …
Response attribution not verified
#138 —
Recommendation: The relocation of NHS services requires partnership working and capital investment from the Government, which is not always straightforward. The previous Government’s Cavell Centre programme supported six pilot projects to build NHS centres designed to bring together health and social …
Response attribution not verified
#15 —
Recommendation: We welcome the government’s programmes to increase access to mental health support for people in the homelessness system. We would like to see improved access to referral pathways between health and housing services in areas with high levels of Black …
Response status not verified
#14 —
Recommendation: The Home Office and the police should be added to the list of public bodies subject to the statutory ‘duty to refer’ and included in the forthcoming proposals for a ‘duty to collaborate’. (Recommendation, Paragraph 75)
Response status not verified
#30 —
Recommendation: We welcome the Minister’s recognition that the different parts of government—including DWP and the NHS—are ‘in this together.’ As we said in our Pensioner Poverty report, a whole system approach to prevention is needed if the government is to achieve …
Response status not verified
#15 —
Recommendation: In its official response to this report, we request that the government provide more information about how the new Private Rented Sector Ombudsman will interact with local authorities and the courts. (Recommendation, Paragraph 76)
Response status not verified
#14 —
Recommendation: We welcome the creation of a new Private Rented Sector Ombudsman. If implemented well, we are confident that the new ombudsman will provide an effective alternative route for redress. However, the government needs to provide further clarity on how the …
Response status not verified
#14 —
Recommendation: In response to this report DWP should clearly outline indicative delivery and rollout arrangements for WorkWell. This should include referral readiness and the point at which full delivery is expected in each Integrated Care Board (ICB), as well as how …
Response status not verified
#13 —
Recommendation: We support the national rollout of WorkWell. By strengthening coordination between health and employment services, WorkWell has the potential to support clearer pathways between programmes, including Connect to Work, and to contribute to wider system change. Effective arrangements for information …
Response status not verified
#4 —
Recommendation: We recommend that the Health Bill be amended to require the Secretary of State to review the effective use of Section 75 of the NHS Act 2006, and to produce guidance to support NHS bodies and local authorities making use …
Response status not verified
#3 —
Recommendation: We believe that this bill is a missed opportunity for the government to either reform and promote the use of section 75 arrangements, or to provide an alternative mechanism that it believes is more effective in addressing the challenges funding …
Response status not verified
#2 —
Recommendation: We recommend that the statutory requirement for ICBs to have at least one member jointly nominated by local authorities be retained. (Recommendation, Paragraph 8)
Response status not verified
#1 —
Recommendation: In our Palliative Care report, we urged the government to reconsider its decision to remove local authority representation on ICBs. We remain convinced that removing their representation from ICBs is a damaging move that will undermine the government’s efforts to …
Response status not verified
#7 —
Recommendation: At the best of times, release from prison can be a difficult time for many, however, Covid-19 has created a very different environment for those released from prison to enter. Service provision in the community has changed substantially and it …
Response attribution not verified
#18 —
Recommendation: We are concerned that innovative technology-based solutions are being explored across the theatre, sports and festivals sectors without full collaboration between them. This is exactly the issue the Cultural Renewal Taskforce was set up to address. The Cultural Renewal Taskforce …
Response attribution not verified
#18 —
Recommendation: Prisons, local authorities, and health and care providers do not always work together effectively to ensure continuity of older prisoners’ health and social care. This can have a detrimental impact on an individual’s health and their efforts to re-integrate into …
Response attribution not verified
#12 —
Recommendation: An ageing prison population will increase demand for social care services in prisons. While the Care Act 2014 has brought some improvements, standards of provision are highly variable across the estate. A more strategic and coordinated approach is needed to …
Response attribution not verified
HSSIB safety recommendations(58)— showing 50 strongest matches
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide details of the support and resource expected from integrated care boards to facilitate cross-organisational investigations, to help reduce uncertainty and variation in practice.
Learning Prompt
Patient care in temporary care environments
Does your organisation have aligned processes across different departments, including the availability of specialty services to help facilitate the movement of patients to the right place of care as soon as possible?
Learning Prompt
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that the Department of Health and Social Care works with local authorities to redesign how the health and social care needs of prisons’ populations are assessed. This is to ensure that appropriate services are commissioned to meet the …
Safety Recommendation
Healthcare provision in prisons: needs assessments and disability access
HSSIB recommends that HM Prison and Probation Service, in collaboration with the Department of Health and Social Care, formalises arrangements for alerting healthcare commissioners and providers to changes in prison populations likely to impact on healthcare provision requirements. This is …
Safety Recommendation
Healthcare provision in prisons: continuity of care
Prisons and NHS trusts can improve patient safety by working together to ensure outpatient escort availability and the timing of hospital appointments is aligned to fit with the prisons’ and the trusts’ regimes. This will reduce the administrative burden and …
Safety Observation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that the Association of Ambulance Chief Executives, in collaboration with HM Prison and Probation Service, sets up formal communication routes, at both national and regional levels, between prison and ambulance services to escalate concerns, review risks and improve …
Safety Recommendation
Insulin: supporting safe self-administration in vulnerable patient groups in the community
HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a disability
HSSIB recommends that NHS England/Department of Health and Social Care provides guidance to integrated care boards and community providers setting out expectations for service models that empower and support people to manage and administer insulin in community settings. This is …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a mental health problem
HSSIB recommends that Royal College of Psychiatrists, through collaboration with relevant stakeholders, develops a strategy that: 1) supports consistent recognition of patients with type 1 diabetes and evidence of disordered eating; and 2) identifies associated care responsibilities for providers of …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a mental health problem
HSSIB recommends that NHS England/Department of Health and Social Care develops a strategy for improving collaboration between mental health teams and specialist diabetes services, that includes consideration of responsibilities for integrated working at national, regional and local levels. This is …
Safety Recommendation
Medication not given: discharge from an acute hospital to the community
How does your organisation work with other services to help provide co-ordinated care for patients discharged home who need insulin support?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board?
Learning Prompt
Surgical care of NHS patients in independent hospitals
HSIB recommends that NHS England and NHS Improvement ensures that effective processes have been implemented in integrated care systems to identify local capability and capacity of their independent acute hospitals.
Safety Recommendation
Recognition of the acutely ill infant
HSIB recommends that the Chair of the NHS System-wide Paediatric Observations Tracking (SPOT) Programme ensures that the Association of Ambulance Chief Executives, community NHS 111 providers and primary care services are integral members of the NHS SPOT Programme.
Safety Recommendation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to …
HSIB recommends that Trust B works collaboratively with Trust A to develop a harmonised, cross-trust stroke policy with a clearly defined joint emergency department overnight stroke protocol for FAST-positive patients.
Safety Recommendation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to …
HSIB recommends that the Ambulance Trust works with Trust A and Trust B to ensure that their local stroke policies are aligned and direct ambulance crews to the most appropriate service.
Safety Recommendation
Local integrated investigation pilot 3: Transfer of a patient who had suffered a stroke to …
HSIB recommends that Trust A and Trust B update the information provided to the Directory of Service on the availability of stroke services once they have created a harmonised cross-trust stroke policy.
Safety Recommendation
Provision of care for children and young people when accessing specialist gender dysphoria services
It may be beneficial if local healthcare commissioners had up-to-date and easily accessible resources to identify all relevant services within a locality that could provide support to patients with gender identity concerns.
Safety Observation
Provision of care for children and young people when accessing specialist gender dysphoria services
HSIB recommends that NHS England and NHS Improvement incorporates the findings of this investigation into plans to further review and develop the service specifications for specialised gender dysphoria services. This should include further work with relevant stakeholders to: A Identify …
Safety Recommendation
Variations in the delivery of palliative care services to adults
Work with integrated care partnerships to account for capacity and resource in social care when planning palliative and end of life care services.
Safety Action
Variations in the delivery of palliative care services to adults
Support collaboration between health and care organisations to define clear routes of support for people in and out of normal working hours to ensure they know how to access help for palliative care and end of life needs.
Safety Action
Harm caused by delays in transferring patients to the right place of care
It may be beneficial for there to be a whole-system patient safety accountability and responsibility framework that spans health and social care.
Safety Observation
Harm caused by delays in transferring patients to the right place of care
HSIB recommends that the Department of Health and Social Care conduct an integrated review of the health and social care system to identify risks to patient safety spanning the system arising from challenges in constraints, demand, capacity and flow of …
Safety Recommendation
Advanced airway management in patients with a known complex disease
Healthcare organisations that commission elective (planned) surgical services for people with mucopolysaccharidoses (MPS) can improve safety by involving healthcare professionals from different disciplines who are experienced in airway evaluation and management, before, during and after a person’s surgery.
Safety Observation
Sexual safety: the implications for patient safety
Health and care organisations can reduce duplication of effort within sexual safety improvement work by increasing co-ordination and collaboration. This should accelerate and enhance the potential improvements across organisations.
Safety Observation
Safety management
HSSIB suggests that integrated care boards seek assurance of how health and care providers will work together when commissioning services, so that patient safety can be managed across health and care providers. This is to help support the visibility and …
Safety Action
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for …
HSSIB recommends that the Secretary of State for Health and Social Care directs and oversees the identification and development of a patient safety responsibilities and accountabilities strategy related to health and social care integration. This is to support the management …
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
Children and young people’s mental health services and adult mental health services can improve patient safety by having more aligned thresholds and criteria to access care, and improved data sources to inform decision making. This is to support closer alignment …
Safety Observation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that the Department of Health and Social Care works across government to identify opportunities to support closer cooperation between local government, education and health systems for the safe and effective transition of young people into adulthood. This is …
Safety Recommendation
Investigation report: Mental health inpatient settings - out of area placements
Health and social care organisations can improve patient safety by working together and embedding mental health social workers from the local authority in mental health acute hospitals. This can ensure that patients’ holistic health and social care needs are considered …
Safety Observation
Investigation report: Mental health inpatient settings - out of area placements
HSSIB recommends that the Department of Health and Social Care works across government to review the statutory instruments, business processes and regulations that govern mental health services, social care and housing services impacting on mental health out of area placements …
Safety Recommendation
Sepsis: a patient with diabetes and a foot infection
Review and update the requirements of vascular service provision between Hospital A and Hospital B.
Area of Improvement
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Primary, community and secondary healthcare providers can improve patient safety by working collaboratively to recognise and mitigate local system challenges and constraints that prevent the: communication of high-quality safety-critical information about patients completion of actions for ongoing patient care within …
Safety Observation
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
HSSIB recommends that the Department of Health and Social Care works with NHS England and other stakeholders, to develop a strategy that ensures that all diseases are given parity and that all people with a long-term condition in primary, secondary, …
Safety Recommendation
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
HSSIB recommends that NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and …
Safety Recommendation
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
Variability in the medical support accessed by nursing staff due to the medical care arrangements for the nursing home. Area of improvement 2
Area of Improvement
Electronic patient record systems – electronic referrals for ongoing care
HSSIB recommends that NHS England/Department of Health and Social Care undertakes a rapid evaluation of advice and guidance processes, including as part of single point of access. This is in order to address the varying risks to patient safety created …
Safety Recommendation
Transition from child and adolescent mental health services to adult mental health services
That NHS England and NHS Improvement work with commissioners and providers of mental health services to ensure that the care of a young person before, during and after transition is shared in line with best practice, including joint agency working.
Safety Recommendation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Further integration of clinical pharmacy services within the MDT and within strategic decision making may improve a shared understanding of which medicines and situations place patients at greater risk of serious medication errors occurring.
Safety Observation
Management of venous thromboembolism risk in patients following thrombolysis for an acute stroke
The advantages of multidisciplinary team (MDT) working are well known. It would be beneficial for organisations to ensure that stroke units are structured to ensure the optimal functioning of the MDT. To achieve this requires strong leadership, planning and a …
Safety Observation
Variations in the delivery of palliative care services to adults
Support collaboration between health and care organisations, including those in the voluntary and charitable sectors, to encourage more open discussions about death and dying in their local communities, accounting for their population demographics.
Safety Action
Harm caused by delays in transferring patients to the right place of care
HSIB recommends that the Department of Health and Social Care develops and implements a patient safety accountability framework that spans the health and social care system. This is to help address the lack of accountability relating to patient safety risks …
Safety Recommendation
Safety management
Health and care organisations can improve patient safety by working together to identify the challenges with the practical use of the Learn from Patient Safety Events service to enable the identification of risks that span multiple providers. This is intended …
Safety Observation
Mental health inpatient settings: Creating conditions for learning from deaths in mental health inpatient services …
Integrated care boards and organisations that provide mental health care can improve patient safety by working together to support the facilitation of cross-organisational investigations and learning. This should be achieved in a way that enables people involved in an investigation …
Safety Observation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
When exploring safety accountability, views varied as to whether individual providers or people were accountable, or the integrated care board (ICB). Stakeholders described that accountabilities needed to be clearly defined, with collaboration between providers to ensure processes – such as …
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Does your organisation have pathways for primary and community care to troubleshoot incomplete or ambiguous information in discharge correspondence?
Learning Prompt
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned?
Learning Prompt
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
Health and care organisations can improve patient safety by allocating a point of contact for patients and/or their carers when people are discharged from services out of normal working hours. This will ensure patients and their carers are able to …
Safety Observation
NCEPOD recommendations(71)— showing 50 strongest matches
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
CQC inspection actions(49)
The Ipswich Hospital
The service should ensure multidisciplinary team working is improved.
Should Do
Northwick Park Hospital
The trust should consider a cancer strategy which focuses on local priorities.
Should Do
Northwick Park Hospital
The trust should consider a local cancer strategy, to ensure cancer services are aligned to local commissioning and provision of services to support people during and after their cancer treatment.
Should Do
Northwick Park Hospital
The trust should work with system partners to ensure there is a seamless service and clarity about clinical decision making in the provision of care at the trust and other NHS providers of mental healthcare.
Should Do
Ealing Hospital
The trust should consider a local cancer strategy, to ensure cancer services are aligned to local commissioning and provision of services to support people during and after their cancer treatment.
Should Do
Ealing Hospital
The trust should work with system partners to ensure there is a seamless service and clarity about clinical decision making in the provision of care at the trust and other NHS providers of mental healthcare.
Should Do
Diana Princess of Wales Hospital
The service should ensure that bereavement staff are invited to relevant end of life team meetings.
Should Do
Diana Princess of Wales Hospital
The service should ensure there are formalised referral processes to the chaplaincy teams.
Should Do
Diana Princess of Wales Hospital
The service must ensure there is a formalised referral processes to the EoL teams with effective cross site cover.
Must Do
Clatterbridge Hospital
The services should continue to consider ways to resolve issues with transitional pathways for patients with complex care needs.
Should Do
Clatterbridge Hospital
The services should work in collaboration with other provider to ensure appropriate assessment of children and young people attending with symptoms of acute mental health illness.
Should Do
Clatterbridge Hospital
The services should work with others in the wider local system to ensure care is planned and provided in a way that meets the needs of local people.
Should Do
St Benedict's Hospice
The service should continue to address the challenges of the organisational structural differences for community services for children and young people across Sunderland and South Tyneside to improve communication and consistency.
Should Do
St Benedict's Hospice
The trust should continue to embed and develop understanding of community services within the executive team to enable them to fully understand the challenges and integrate the different teams.
Should Do
Royal Blackburn Hospital
The service should ensure that continues to work closely with all system partners to tackle the capacity pressures on urgent and emergency care in the integrated care system.
Should Do
North Tyneside General Hospital
The trust should develop and broaden it’s capacity within community services to support the flow through acute services.
Should Do
Newark Hospital
The trust should work closely with the local hospice in agreeing a service level agreement.
Should Do
London Ambulance Service Headquarters
Liaise with the clinical commissioning group to discuss ways to improve the Directory of Services.
Should Do
Durham Diagnostics and Treatment Centre
The service should continue to address the challenges of the organisational structural differences for community services for children and young people across Sunderland and South Tyneside to improve communication and consistency.
Should Do
Durham Diagnostics and Treatment Centre
The trust should continue to embed and develop understanding of community services within the executive team to enable them to fully understand the challenges and integrate the different teams.
Should Do
Countess Mountbatten House
The hospice at home service is developed with partners, as an integral component of community end of life care.
Should Do
Bushey Fields Hospital
Improve levels of engagement with the IMHA service
Should Do
Berwick Infirmary
The trust should develop and broaden it’s capacity within community services to support the flow through acute services.
Should Do
Alnwick Infirmary
The trust should develop and broaden it’s capacity within community services to support the flow through acute services.
Should Do
The Princess Royal Hospital
The trust should continue to work with partner organisations to improve discharges.
Should Do
Lister Hospital
The trust must ensure that information sharing and planning with social care providers is timely to ensure safe and timely discharge from the service.
Must Do
Clatterbridge Hospital
The services should improve the patient and family room areas to provide more information regarding health promotion and services for people at the hospital and within the community.
Should Do
Clatterbridge Hospital
The services should consider how all healthcare professionals work together consistently to benefit patients.
Should Do
Royal Sussex County Hospital
The trust should continue the work that had already started to integrate the cardiac critical care unit with the general and neuro critical care units.
Should Do
Royal Sussex County Hospital
The trust should ensure that when developing or extending services, the pharmacy service is involved in planning and appropriate resources are provided
Should Do
Newark Hospital
The service should continue to develop ways in which they can improve access to all multidisciplinary services in line with national guidance.
Should Do
Durham Diagnostics and Treatment Centre
The service should develop a vision and future plan for intermediate care.
Should Do
Birmingham Children's Hospital
The trust should consider effective pathways are fully embedded between the Child and Adolescent Mental Health Service (CAMHS) and the emergency department. Where the CAMHS team do not respond within agreed timescales, the service should ensure staff are escalating these …
Should Do
Westmorland General Hospital
The trust must improve the multidisciplinary working and culture between the department and specialities and speciality teams to maximise patient care and outcomes.
Must Do
University Hospital Aintree
The trust should consider working with system partners to improve care pathways for patients who attend the emergency department with a mental health condition who need to be transferred to another place of care.
Should Do
Royal Victoria Infirmary
The service must ensure that timely care planning takes place where responsibility for care and treatment is shared with, or transferred to others services.
Must Do
Royal Shrewsbury Hospital
The trust should continue to work with partner organisationsto improvedischarges.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that training on the electronic palliative care coordination system (EPaCCS) is delivered to eligible staff.
Should Do
King George Hospital
The service should continue to work with partner organisations to ensure mental health patients are provided with timely assessments.
Should Do
St Benedict's Hospice
The service should consider ways of strengthening and developing joint governance systems for the services within the trust to provide oversight of performance and risk as a whole.
Should Do
St Benedict's Hospice
The service must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must Do
St Benedict's Hospice
The trust must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must Do
Royal Sussex County Hospital
The trust should work with the neighbouring mental health trust to reduce the delays in admitting patients to specialist mental health units.
Should Do
Royal Bournemouth Hospital
The trust should continue working with partners to reduce delayed transfers of care from hospital.
Should Do
Family Nurse Partnership & Health Visiting
The service should ensure consistent approaches to frequency of meetings and sharing risk information with other agencies, for example with local GP practices.
Should Do
Bridlington Hospital
The service should work towards reducing length of stay for non-elective patients.
Should Do
Tralee Rest Home
The provider could develop closer working between sister services and this may serve to improve consistency and best practice.
Should Do
Gillmoss Medical Centre
Implementadetailedstrategytosupporthighqualityandsustainablecare.
Should Do
Shining Star Home Care Limited
Improvements were required to ensure the provider worked in partnership with external agencies and relatives to ensure people received a holistic service.
Should Do
HMICFRS recommendations(2)
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables should explore opportunities to improve how their force works with partners to contribute to a multi-agency response to stalking, including healthcare, CPS, probation collaboration, inter-force collaboration, and MAPPA utilisation for stalking offender management.
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables and police and crime commissioners should work together to review commissioning arrangements and embed collaborative working and information sharing between policing and victim support services.
Recommendation
PPO death in custody recommendations(9)
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC …
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC and NHS England, should explore options for developing a pathway for prisoners who have been assessed as needing residential social care to access an appropriate care setting. This work should …
The Head of Healthcare
The Head of Healthcare should ensure that there is a local process to maintain oversight of regional bed referrals and any required escalation.
The Head of Healthcare
there are clear processes and pathways in place to enable staff to make timely onward referrals;
The Head of Healthcare
improve communication between healthcare and mental health services and ensure that feedback and advice on how to manage complex cases is provided to those who make referrals;
The Governor and Head of Healthcare
The Governor of Wakefield and Head of Healthcare should develop and implement a multidisciplinary information-sharing protocol, for the purposes of care planning and risk assessments, that ensures information is shared appropriately between disciplines inputting into an individual’s care.
The Head of Healthcare (HMP Stafford)
The Head of Healthcare should review and improve communication methods for liaising with hospital consultants and clinics, and evidence changes in system management to NHS England commissioners.
The Head of Healthcare
The Head of Healthcare should engage with a senior clinical hospital colleague in order to improve the discharge information process between the hospital provider and HMP Stafford.
The Director General of HMPPS, NHS England, and the Association …
The Director General of HMPPS should work with NHS England and the Association of Directors of Adult Social Services with the aim of developing a strategy to meet the needs of prisoners not suitable for release but who need an …
The Governor and Head of Leeds Probation Delivery Unit
Information sharing between all relevant agencies is key to release planning and the Governor and Head of Leeds Probation Delivery Unit may want to reflect on the learning from this case.
IOPC learning recommendations(5)
Recommendations - West Midlands Police, June 2021
The IOPC recommends that West Midlands Police consider the benefits of implementing a protocol with relevant third parties, such as Housing providers, when dealing with any request for a welfare check. This recommendation is made as the result of a …
Recommendations - Cambridgeshire Constabulary, January 2021
The IOPC recommends that Cambridgeshire Constabulary considers working with local health boards to amend their inter-agency agreement to enable a mental health assessment made by Norfolk health care professionals to be accepted by Cambridgeshire health boards and vice versa. The …
Recommendations - Metropolitan Police Service, March 2021
The IOPC recognise the protracted nature of drafting and agreeing MOUs, therefore the IOPC recommend that in any event the Metropolitan Police Service (MPS) should create and deliver joint mental health awareness training with London-based Mental Health trusts, including the …
Recommendations - Metropolitan Police Service, March 2021
The IOPC recommends that the Metropolitan Police Service (MPS) create a Memorandum of Understanding (MOU) between all London-based Mental Health Trusts and the PAN London Mental Health Group. It is recommended that this MOU includes the following points: joint mental …
Recommendations - Gwent Police, February 2021
The IOPC recommends that Gwent Police engages with external agencies, who regularly request the police to conduct welfare checks on their behalf, and establishes a Memorandum of Understanding. This is to ensure that both the agencies and Gwent Police are …
NAO audit recommendations(27)
Reforming adult social care in England
As it turns its attention to charging reform alongside system reform, DHSC should publish a long-term plan mapping its reform activity and the funding it will need to achieve its planned outcomes
Rejected
Reforming adult social care in England
As it turns its attention to charging reform alongside system reform, DHSC should ensure it has the resources it will require within the Department, in terms of both capacity and capability to deliver the next stage of reform
Accepted
Reforming adult social care in England
DHSC should, in the near term, assess the impact of its current and planned reform interventions on local authorities, and other stakeholders to ensure that the cumulative impact of its policies are manageable;
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
a) DHSC and the Department for Levelling Up, Housing & Communities should, by April 2023, establish transparent arrangements across government and with wider stakeholders to tackle the drivers of poor health outcomes, including education, employment, benefits, and transport;
Accepted
The adult social care market in England
The Department should: a) as a priority, set out a cross-government, long-term, funded vision for care. It should collaborate with the Ministry and local government in particular; factoring in sector and user perspectives, such as people with lived experience;
Accepted
The supply of personal protective equipment (PPE) during the COVID-19 pandemic
Despite efforts to integrate them over the years, health and social care have continued to be separate systems. During this crisis the social care sector was hit hard by shortages of PPE, and government needs to understand why national bodies …
Partially accepted
Local government financial sustainability
As part of the spending review, and to support a cross-departmental approach, we recommend that HM Treasury: work to provide a spending framework that supports the government?s plans for local government funding and service reform
Accepted
Local government financial sustainability
We recommend that MHCLG: work with the local government sector to improve the transparency and consistency of local authority reporting on reserves to aid understanding of local authorities? overall financial positions;
Accepted
Local government financial sustainability
We recommend that MHCLG: explore how the impact of preventative services can be evaluated and incentivised to deliver better outcomes and improved value for money
Accepted
Local government financial sustainability
We recommend that MHCLG build on recent announcements to develop a whole-system approach to local government financial sustainability. This approach would consider interdependencies and consequences across services and departmental boundaries and should be underpinned by clear expectations of local government. …
Accepted
Local government financial sustainability
We recommend that MHCLG build on recent announcements to develop a whole-system approach to local government financial sustainability. This approach would consider interdependencies and consequences across services and departmental boundaries and should be underpinned by clear expectations of local government. …
Accepted
Support for children and young people with special educational needs
DfE and the wider government should: c) build a more integrated system by, for example, developing a shared understanding of how identifying and supporting SEN should be prioritised, including within the health system; ensure those with accountability can act, including …
Accepted
Reforming adult social care in England
As it turns its attention to charging reform alongside system reform, DHSC should review its arrangements for delivering and overseeing its reform activity, incorporating external challenge, and to conclude whether a more integrated approach is required going forward.
Accepted
Reforming adult social care in England
DHSC should, in the near term, set out a costed plan to the sector for implementing charging reform from October 2025, incorporating lessons learnt so far
Rejected
Reforming adult social care in England
DHSC should, in the near term, review its portfolio reporting to ensure that it provides the management information needed to give assurance around overall progress and management of risks to delivery
Accepted
Improving educational outcomes for disadvantaged children
DfE should take a clearer whole-system approach by more clearly setting out how the range of its interventions come together, to help: understand how they individually and collectively support the attainment of disadvantaged children; ensure that objectives are aligned; and …
Accepted
Reducing the backlog in criminal courts
b) develop a shared understanding of the capacity and capability of other parts of the criminal justice system, including the CPS and the legal professions, to support recovery in criminal courts.
Accepted
Reducing the backlog in criminal courts
• set reasonable expectations around waiting times by case type, acknowledging the responsibility of the judiciary.
Accepted
Reducing the backlog in criminal courts
• align recovery funding, planning and reporting across criminal justice agencies; and
Accepted
Reducing the backlog in criminal courts
The Ministry should: a) agree with other criminal justice agencies a set of shared, published objectives for recovery in criminal courts that explicitly consider the implications for the rest of the criminal justice system. It should use these shared objectives …
Accepted
Test and trace in England – progress update
e) The Department, through NHST&T, and UKHSA if responsible, should agree with NHS England and NHS Improvement whether and how the laboratory capacity built up for COVID-19 tests will be used by the NHS. It should publish by March 2022 …
Partially accepted
The adult social care market in England
f) consult on options for enhancing support for local commissioners which promotes an integrated approach and incentivises commissioning for outcomes; and
Accepted
Local government finance in the pandemic
To further improve other elements: b) other departments, drawing on the support of the Department, should improve their links with, and understanding of, local authorities, drawing on learning from the Social Care Sector COVID-19 Support Taskforce;
Accepted
The effectiveness of government in tackling homelessness
We recommend that DLUHC should lead on adopting a genuinely cross-departmental approach to tackling homelessness, which might involve establishing a dedicated joint unit to oversee the implementation of the approach
Accepted
Improving educational outcomes for disadvantaged children
DfE should take a clearer whole-system approach by setting out how it will more effectively engage with wider government to help develop a shared vision, robust joint risk assessment, clear responsibilities, and an understanding of how respective departmental priorities could …
Accepted
NHS Financial Management and Sustainability
NHSE and DHSC should revisit their understanding of the reasons some ICBs and other NHS bodies have persistent underlying weaknesses that lead them to struggle with their finances. They should then develop a plan to remove these barriers.
Accepted
NHS Financial Management and Sustainability
NHSE needs to complete its annual planning processes with ICSs well in advance of each financial year starting. All key players, including NHSE, DHSC and HM Treasury, have roles to play to enable planning guidance to be provided in a …
Accepted
IMB individual recommendations(122)— showing 50 strongest matches
Bedford (2022)
We believe that there would be significant benefits in the co-location of healthcare and mental health services and are disappointed that this has not yet happened.
Governor / Director
Bronzefield (2024)
How does NHS England plan to improve the integration of the healthcare services in Bronzefield? (6.1)
NHS / Healthcare Provider
In Progress
Bronzefield (2024)
How does the Minister plan to improve the integration of the healthcare services (under NHS England commissioning) within Bronzefield? (6.1)
Ministry of Justice
In Progress
Derwentside IRC (2023)
To establish or improve pathways with local authorities and other external agencies, including probation, to enable prompt access to housing, social support and other services, which are required to be put in place before vulnerable women leave detention
Home Office
Thameside (2024)
The lack of adequate probation support, both for prisoners about to be released and in the community once they are released, is one highlighted by this Board and other Boards for a number of years. It is widely accepted that such support reduces recidivism. Will the new Minister consider: o an increase in the probation support available for prisoners; and …
Ministry of Justice
In Progress
Durham (2024)
How will you ensure the alignment of operational and healthcare regimes?
Governor / Director
Nottingham (2025)
How does the Prison Service plan to ensure a more cohesive working relationship between the healthcare provider and the prison?
HMPPS
Implemented
Cardiff IMB (2025)
Sut bydd y carchar yn gweithio gyda chyngor Caerdydd i sefydlu proses gofal cymdeithasol ffurfiol a chadarn, o ystyried nad oes un yn bodoli, fel yr amlygwyd yn yr Asesiad o Anghenion Iechyd a Gofal Cymdeithasol?
Governor / Director
Cardiff (2025)
How will the prison work with Cardiff council to establish a formal and robust social care process, given that none exists, as highlighted in the H&SCNA?
Governor / Director
Bronzefield (2025)
What further steps will the Minister take to address the integration of the healthcare services (under NHS England commissioning) within Bronzefield, notwithstanding the Memorandum of Understanding referred to in the Minister’s letter of response to the Board’s 2023-2024 annual report (on 17 January 2025) (6.1)?
Ministry of Justice
In Progress
The Verne (2020)
The Board encourages the Governor, in collaboration with Dorset Council, to review the long-term provision of social care needs for the current population.
Governor / Director
Implemented
Long Lartin (2020)
The Board believes that there is a need for closer cooperation between HMPPS management and the healthcare providers, in order to help them to achieve a better service.
Governor / Director
In Progress
Bedford (2020)
Explore the possibilities of co-locating the healthcare team and the mental healthcare team.
Governor / Director
The Verne (2021)
The Board urges HMPPS to expedite the establishment of the ‘community hospital’ and a facility enabling 24hr social care at The Verne.
HMPPS
In Progress
The Verne (2022)
The Board urges HMPPS to expedite the establishment of a facility enabling 24-hour social care at The Verne (para. 6.3.5).
HMPPS
Downview (2022)
It has been regrettable that there has been such a lack of stability with the management of healthcare during the reporting year and this has undoubtedly impacted on provision. We are reassured to see a permanent healthcare head appointed shortly after the end of the reporting period, which hopefully will lead to a more concerted effort on behalf of the …
Governor / Director
Woodhill (2023)
To work with colleagues in the Department of Health and Social Care to consider how the pathway through secondary care could be streamlined for prisoners who are transferred after their referral.
Ministry of Justice
Noted
Thameside (2023)
The Board has been concerned regarding the management of the changeover of healthcare provider; while recognising some disruption was inevitable, the level of disruption has been greater than expected and unacceptable, impacting negatively on prisoners’ ability to access adequate healthcare.
HMPPS
In Progress
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Lowdham Grange (2023)
To strengthen the collaborative working arrangements with the Nottinghamshire Healthcare NHS Trust and its commissioners in order to ensure that the levels of service provided in the prison correspond with the services available in the community. The Board also refers to its concerns about the shortages of healthcare staff in the prison and in particular the lack of night healthcare …
Governor / Director
Hewell (2023)
What is the Prison Service doing to improve the effectiveness of agencies working together to achieve effective release and resettlement? Despite good work being done by individual agencies, we see men being released without the dots having been joined; this negates in-prison work done to achieve positive resettlement and may increase the chances of homelessness, unemployment and re-offending.
HMPPS
Downview (2023)
Does the prison consider there to be a benefit in the healthcare/prison partnership meetings and, if so, will appropriate resources be dedicated to them?
Governor / Director
Askham Grange (2023)
Can the Prison Service consider improving the provision of community offender managers to help speed up access to ROTLs and improve release planning?
HMPPS
In Progress
Springhill (2024)
The Board continues to report issues with securing the necessary information and engagement from outside probation and other agencies, which significantly delay men’s access to release on temporary licence (ROTL). An issue which is exacerbated by the introduction of new early release schemes. What more does the Prison Service intend to do to improve the capacity of outside probation and …
HMPPS
In Progress
Haverigg (2024)
When will the Minister improve the range of support services for an increasing number of very frail elderly prisoners (80+ years) who have complex physical, mental health and social care needs? Does the Minister consider that prison is a suitable environment for this cohort of prisoners? If not, what are the alternatives?
Ministry of Justice
In Progress
Dartmoor (2024)
What progress has been made on the provision of overnight care at a category C prison in Devon? When will it be introduced?
HMPPS
In Progress
Peterborough (2025)
For the men’s prison, what specific steps are being taken to ensure that the care of prisoners benefits fully from a multidisciplinary approach that makes better use of the resources now available?
Governor / Director
Implemented
Durham (2025)
How will you ensure the alignment of operational and healthcare regimes? (6.2.13)
Governor / Director
Ashfield (2025)
Pressure on probation services inside and outside prison. Concern about prisoners being released without appropriate accommodation. What further measures are being taken to address this problem?
Other
In Progress
Bronzefield (2025)
How does NHS England plan to improve the integration of healthcare services in Bronzefield (6.1)?
NHS / Healthcare Provider
In Progress
Thorn Cross (2020)
An additional concern is the healthcare needs of prisoners who transfer to Thorn Cross while in the process of hospital and other clinical treatment at their current establishment. These prisoners, who require ongoing treatment at specialist centres, cannot easily or quickly be referred to local medical facilities. To enable these prisoners to continue their treatment, significant additional resource requirements are …
HMPPS
Noted
Hewell (2020)
Similarly, the Board remains concerned about the difficulties encountered in transferring prisoners with severe mental health/behavioural issues to an environment where they can be treated effectively. Again, will the minister work with colleagues in other departments to ensure greater availability of more suitable locations for these prisoners?
Ministry of Justice
In Progress
Styal (2021)
The Board is concerned about the changes to the contracts for Through the Gate (TTG) Services, including the loss of Shelter who are a known and experienced partner. Whilst TTG services will now be managed by the National Probation Service (NPS), there will still be a number of new external partners, replacing the current partners and based around different geographical …
HMPPS
Implemented
Maidstone (2021)
Develop a more integrated relationship with HOIE to ensure fair and humane treatment for foreign national prisoners and their families through improved communication and end of sentence management.
HMPPS
In Progress
Lewes (2021)
Will the Minister engage with the Ministry of Housing, Communities and Local Government to improve the coordination between the prison service and local authorities so that pre-release assessments are completed by both parties in advance of prisoner release in all cases?
Other
In Progress
Gartree (2021)
The Board acknowledges the Minister’s response to the question raised in our last annual report regarding the national partnership agreement for prison healthcare. The Board requests the Minister provide a further update on resources being planned post-Covid-19 to enable the delivery of measures outlined in the partnership agreement specifically for Gartree, as the Board has increasing concerns regarding the mental …
Ministry of Justice
Cookham Wood (2021)
When will the refurbished Phoenix unit be opened as a functioning integrated care unit?
Governor / Director
Implemented
Wayland (2022)
The Board recommends to the Governor that the cooperation/collaboration between the operational and the education contractor sides could be significantly improved in order to make better use of an expensive prisoner rehabilitation resource.
Governor / Director
Styal (2022)
consideration needs to be given to a more holistic, multi-agency approach to release arrangements to ensure fair and consistent access to support.
HMPPS
Hull (2022)
The Board would ask the minister to improve the work of outside contractors and organisations responsible for ensuring appropriate accommodation and support is available on release to reduce the risk of re-offending as they are not communicating effectively with the in-prison resettlement team.
Ministry of Justice
In Progress
Hollesley Bay (2022)
That, as the prison population becomes older, greater attention is paid to the social care agenda and any matters appearing are cross-referenced with the prison’s health service providers.
Governor / Director
Hollesley Bay (2022)
That, as the prison population becomes older, greater attention is paid to the social care agenda and any matters appearing are cross-referenced with the prison’s health service providers.
Governor / Director
Gartree (2022)
Therefore, can the Prison Service confirm to the Board that the integrated health services at Gartree are achieving the outcomes expressed in various commissioning documents, and that the healthcare is equivalent to the local wider community (i.e. the Market Harborough district)?
NHS / Healthcare Provider
Dartmoor (2022)
What is the path for Dartmoor prisoners who require 24-hour health or social care support, or other special equipment or support that Dartmoor is unable to provide?
HMPPS
Thameside (2023)
We ask the Minister to address the shortfalls in probation provision, despite the promised increase in probation staffing, especially in the London area.
Other
In Progress
Portland (2023)
Need for inter-departmental communication relating to prisoners’ pathways to resettlement
Governor / Director
Hewell (2023)
Address significant shortcomings in the immediate practical resettlement needs of men leaving Hewell, including improvement of inter-agency working, so that no man is found wandering up the drive without the means of reaching a safe destination or ability to meet release conditions.
Governor / Director
Usk and Prescoed (2024)
How will the Minister address the issue of access to support for personal social care for the increasing number of prisoners with limited mobility and other disabilities?
Ministry of Justice
In Progress
North Sea Camp (2024)
Whilst this was addressed after last year’s annual report, there are still some apparent delays with community offender managers often taking a long time to update their part of the offender assessment system (OASys) risk assessment paperwork to enable prisoners to sit release on temporary transfer (ROTL) boards.
HMPPS
In Progress
Downview (2024)
How does HMPPS intend to resolve [the lack of commissioned provision for dementia testing in the prison]?
HMPPS
In Progress
Health investigations(1149)
*Mental health homicide investigation legacy report into the care and … — Rec L4
The trust should continue to develop relationships with partnership agencies. This should include reviewing the protocols with partnership agencies to ensure effective communication and information sharing for the safety of patients and the general public e.g. information to service providers such as housing associations and hostels. This should take place …
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xix)
The Council should ensure that in any case in which there is an assessed substantial need for assistance with a social problem careful consideration is given to the feasibility and best means of providing the requisite support.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xviii)
The Trust should devise and operate a definitive system of link working between mental health staff and General Practitioners.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xvii)
The Trust should impress upon service users and their General Practitioners the importance of adherence to the prescribed regime of medication.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xvi)
The Trust should devise and operate a system whereby the prescription of all medication for service users is undertaken solely by psychiatrists unless General Practitioner treatment is in accordance with agreed shared care protocols.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xiv)
The Trust should devise and operate a definitive system of liaison between psychiatrists and depot clinic nurses for both Enhanced and Standard CPA cases.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (vii)
The Trust and Council should ensure that following assessment of a service user entitled to aftercare a care plan is formulated which complies with the requirements of the CPA and Care Management.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (i)
The Central and North West London Mental Health NHS Trust and Brent Council should ensure that the health and social care needs of every service user entitled to aftercare pursuant to section 117 of the Mental Health Act are fully and properly assessed in accordance with the procedures set out …
london
Independent investigation: Sidney Waller, Manchester (2008) — Rec 6
There should be a review of the model of care provided by the Assertive Outreach Team which should include a range of monitoring tools. This review should also examine the stated philosophy of care ensuring that clinical best practice issues are held in balance with those of the service user’s …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 12
The Trust should develop a system to provide the clinical team with access to any required cultural information and external support agencies. The Trust should: develop community outreach and inreach initiatives with the local community in order to establish culturally appropriate liaison; ensure appropriate links are made with different faith …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 1
The Trust should review the emergency out of hours procedures and protocols and make formal written arrangements with each of the „blue light‟ services.
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 12
Social services should ensure that housing providers are aware of the importance of giving early notification of any management problems or rent arrears.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 11
A local protocol should exist between joint mental health services and housing agencies (at a senior level) to facilitate the CPA and local service provision processes.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 10
Where restricted patients are recalled to hospital social services should ensure that there is a joint assessment of the continuing housing needs including consideration of the appropriateness of the previous placement.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
Where restricted patients are recalled to hospital social services should ensure that there is a joint assessment of the continuing housing needs including consideration of the appropriateness of the previous placement.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 3
Social services should ensure that housing providers are aware of the importance of giving early notification of any management problems or rent arrears.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
A local protocol should exist between joint mental health services and housing agencies (at a senior level) to facilitate the CPA and local service provision processes.
south_east
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xvii)
The Trust, the Health Authority and the Social Services Department should review the allocation of resources so as to ensure as far as possible that an adequate range of services is available for individuals with a mental illness or personality disorder who require a medium level of support.
london
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xvi)
The Trust and the Social Services Department should work together to co-ordinate the processes of the CPA and Care Management in order to avoid differences in policy and practice, duplication of effort and inefficient use of resources.
london
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xv)
The Trust and the Social Services Department should ensure that there are effective channels of communication between the medical teams and the Social Services.
london
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xiii)
The Trust should ensure that in any case in which it is suspected that a social problem is significantly contributing to a patient's illness or disorder action is taken with a view to assessing the extent of that problem and that if upon such assessment it is apparent that the …
london
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 11
Given that new protocols have now been put in place the local Housing Associations, the Trust and the commissioners of mental health services should institute a monitoring system to ensure that: the proper roles and responsibilities of these organisation are adhered to; the protocol for sharing information is adhered to; …
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 4
There was a lack of clarity in primary care about accessing the opinion of paediatric services at Rotherham Hospital. To avoid future ambiguity, a written protocol should be produced for the agreed pathway and criteria for referring on for further paediatric assessment from primary care. This should include: the role …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 5
The Metropolitan Police Service and mental health service providers and users should jointly review their arrangements for responding to potentially violent mentally ill persons in the community, with a view to developing a joint policy and operational protocol for managing such incidents. This should include clear guidelines on risk assessment, …
london
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 4
Westminster City Council should review its housing allocation policy and its use of Bed & Breakfast hotels for vulnerable homeless persons with mental health problems, with a view to increasing the supply of appropriate supported accommodation within the borough, and reducing reliance on out-of-borough placements. This review should include a …
london
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 3
Westminster City Council Social Services Department should review its arrangements for liaison with the criminal justice system to ensure that relevant information is exchanged in a timely and effective manner, particularly in relation to bail decisions and the provision of appropriate adult services. This review should include consideration of dedicated …
london
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 7
Given the improvements that the Trust has put in place in SDAS it should now put in place mechanisms to assure itself that: • there is effective and timely communication between its clinical staff and other relevant agencies; • other agencies and professionals who are, or ought to be, involved …
south_west
Independent investigation: Stefan Welch, Brighton (2010) — Rec 5
The Trust will ensure that professional communication and liaison processes are built into all care pathways and all clinical policy and procedure documents. Professional communication and liaison processes will be made explicit regarding the interface between primary and secondary care. This review work will be completed within six months of …
south_east
Independent investigation: Simon Breed, Wood Green (2004) — Rec R4
The trust work with the Metropolitan Police Service and the Crown Prosecution Service to develop protocols to facilitate senior clinical input into decisions to grant bail and decisions to withdraw criminal charges in cases involving mentally disordered offenders.
london
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Given the need for close networking between many agencies and the establishment of supervision registers, some thought should be given by the Department of Health and the professional bodies to drawing on the best practice from child protection in developing an interagency approach to case management for mentally ill patients …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Department of Health should draw together the existing fragmented policy guidance on the role of Local Authority and Health Services staff in the care and after-care of mentally ill people in an integrated document of guidance.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
Health and Social Service Purchasers should review the balance of expenditure to see if a more specialised focus could be developed within the range of community-based residential services in order to provide a locally-based therapeutic service.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Crown Prosecution Service should review its procedures in relation to the prosecution of mentally disordered offenders destined to be routed into the mental health system through a Hospital Order.
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 12
That the Trust should, as soon as is practical, aim to locate psychiatrists and CMHT staff in the same premises in order that they might more easily coordinate the service they provide for their given population, and more easily agree and implement operational protocols and referral systems.(Para 13.3)
midlands
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.12
NHS Trusts, the Probation Service, and the Court Service should review the protocols concerning the sharing of information and in particular pre-sentence reports and psychiatric reports in the case of patients who are receiving treatment at a time when they are before the court, and/or under supervision on licence.
south_west
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.11
On receipt of referrals from prison or probation service the receiving member of the team should request a full history of the patient’s offence record from the referrer, and a member of the team should be allocated to the patient to liaise with the prison or probation service about the …
south_west
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 26
Trusts should ensure that appropriate channels of communication are set up between mental health services and all other agencies working with patients. Care programme meetings could be a forum for this. GPs should be invited to attend all such meetings. Where criminal justice professionals are involved with a patient, the …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 19
Trusts should endeavour to improve the joint working between the addiction services and the adult mental health services, with sharing of information and collaborative care coordination.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 18
Whilst not all patients who have been in medium secure hospitals require ongoing support from forensic services, mechanisms should be put in place to ensure that such patients are discussed with the local forensic services when they are discharged into the community. Ideally, the forensic services should be invited to …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 10
Where there are several agencies involved with a patient and one of those agencies (be it health, social care, probation, or police) has implemented or considered implementing a ‘lone worker’ or ‘home visit’ policy in relation to that patient, this should be communicated to the other agencies involved, either through …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 3
Formal care planning meetings, involving current and future care providers, must be held prior to a patient being discharged from hospital, and prior to any event that is known to have the potential to result in the patient being discharged ( in this case, the expiry of the Section 38 …
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 4.ii
We suggest that the lead clinicians in each of the three MSUs should come to some agreement about how to manage such cases and this agreement should be supported by the Secure Commissioning Team.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 4.i
We recommend that the three North West Medium Secure Units and the Secure Commissioning Team consider how to manage, from a service perspective, a North West patient admitted to a North West Medium Secure Unit who is out of their catchment area. In our view, the Forensic Service needs to …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.h
The Trust and the local social services authority must strengthen their Section 117 procedures. Individuals who are entitled to aftercare should not be discharged from hospital before appropriate aftercare facilities have been identified. Once discharged, the patient’s progress must be actively monitored. Regular Section 117 meetings should be held, with …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.iv.b
We recommend that the Trust consider facilitating team-working development in Bury, with medical staff, in order to encourage efficient multidisciplinary processes and decision-making. The medical staff in particular, need to be included in these proposed team-working developments.
north_west
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec z.
That the trust and Birmingham City Council agree a single management structure for mental health services, joint care programme approach documentation, and joint record-keeping.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec w.
That mental health and learning disability psychiatry services agree a joint clinical appointment at a senior level.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec v.
That simple arrangements are agreed by the mental health trust and learning disability psychiatry services which ensure that patients are jointly assessed whenever one of them thinks that the patient would benefit from shared services.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec m.
That Birmingham City Council discusses with the police the need for the police to establish a dedicated mental health team (in the same way that the police have a dedicated domestic violence team and a dedicated child protection team).
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec l.
That Birmingham City Council considers ‗purchasing‘ a number of police officers for mental health services, who can assist staff in conveying patients to hospital and returning to hospital those absent without leave.
midlands
Scottish Fatal Accident Inquiries(2)
Neil Dempster Reilly
[29] I summarise the following matters which I suggest require further consideration:- (a) that consideration be given to adjusting the current guidelines and training as to the care of drunk and incapable prisoners so as to emphasise the risks to prisoners and that training emphasises the importance of the level of consciousness of the person. (b) that consideration be given …
Jan 2004
Scott Andrew Ross
1. There should be a co-ordinated approach between the hospital and the prison systems in the management of a prisoner’s drug withdrawal. 2. Those managing benzodiazapine withdrawal should consider carefully the proper dosage required for safe discontinuation. Under-prescription in respect of benzodiazapine discontinuation may cause seizures, which can cause brain damage and death; the expert evidence was that overprescription was …
Feb 2024
Custody
4 recs
Article 2 learning points(10)
— LP 8
From a systems point of view, nationally, we further recommend that consideration should be given (a) to the development of a multidisciplinary record, in which Education staff and Chaplains document significant encounters with prisoners, including those not on an ACCT, and (b) to how information systems and care-planning can become …
HMPPS
Accepted
— LP 7
We recommend that, nationally, regarding prisoners on an ACCT, (a) all staff, whatever their profession, having contact with them should record this contact in the ACCT document and (b) that all staff, whatever their profession, involved in their care should attend ACCT reviews.
HMPPS
Accepted
— LP 3
We recommend that across the Prison Service Estate there is more focus on conducting full psychiatric and psychological assessments of prisoners, particularly those with complex needs. This should include the gathering and assimilation of all relevant previous records. This process should be followed by a full psychological formulation with longitudinal, …
HMPPS
Accepted
— LP 6
There should be proportionate information sharing between healthcare and non-healthcare staff so that all staff are aware of the person’s needs, risks, risk factors and likely triggers. Some of this information exchange will be via the ACCT process but there should also be robust handovers at times when staff change …
HMP Altcourse and HMPPS
Accepted
— LP 23
We recommend that efforts are made to ensure that representatives from Healthcare units across the Prison Estate meet on a regular basis. We feel that the key to making this a reality is ensuring that the agenda for such meetings is clear and agreed as a group. Meetings should then …
HMPPS
Accepted
— LP 19
We recommend that officers’ attendance at ward rounds is embedded as a norm on HMP Pentonville’s Healthcare unit, if this is not already the case. This should help further improve understanding and promote a sense of collegiate working among discipline and clinical staff.
PPG
Accepted
— LP 1
At an organisational and cultural level, we recommend that further measures are taken to close the perceived gap between the main prison and the Healthcare unit at HMP Pentonville. This should help create a greater sense that HMP Pentonville is functioning as one organisation, comprised of staff and managers working …
HMPPS
Accepted
— LP K
A multi-disciplinary system for managing Complex Cases should be in place to deal with prisoners such as AC who suffer from a combination of health and behavioural problems.
HMPPS and PPG
— LP G
The partners involved in providing health care to prisoners with mental health problems must be absolutely clear about which service or services have responsibility for prescribing anti-psychotic medication and develop systems to ensure it is prescribed in a timely fashion.
PPG
Implemented
— LP 13
We recommend that the managers responsible for the Southampton court custody suite work with the Hampshire Liaison and Diversion Service to ensure that the service is well understood by custody staff and used effectively.
HMPPS
Accepted
Detention investigations(11)
Assessment of government progress in implementing the report on the … — Rec 23
The Home Offce and Department of Health and Social Care should prepare a joint communication to IRC healthcare teams clearly laying out health-based entitlements for former detainees released into the community.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 6
Weekly multi-disciplinary review meetings should be held at all IRCs to review and progress cases and ensure appropriate care for the most vulnerable individuals in each centre. These meetings should include a range of managers and staff, and crucially should involve the dialling in of the relevant caseworker for each …
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R28
The centre manager and senior Serco managers should continue to engage at all levels with NHS commissioners and G4S to ensure that concerns about the healthcare provision at Yarl’s Wood are addressed.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 58
I recommend that the Home Office, NHS England, and the Department for Health develop a joint action plan to improve the provision of mental health services for those in immigration detention.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 44
I recommend the Home Offce establish an Alternative to Detention project for vulnerable persons who would otherwise be at risk of being detained.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 28
The Home Offce, working with the National Probation Service and Community Rehabilitation Companies, should consider how far vulnerable detainees released from detention can be offered appropriate support and supervision.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 43
I recommend that the Detention Action project for ex-offenders in the community be expanded.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 3
The Home Offce should establish a joint policy with HMPPS on provision for those held in prison under immigration powers.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 17
I recommend that the Home Office consider establishing a joint policy with NOMS on provision for those held in prison under immigration powers.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R44
G4S and the Home Office should discuss relocating the Forward Trust’s office at Brook House so that detainees have ready access to it. (To be completed within 3 months)
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 2
The Home Office should consider how far it can encourage a more cohesive system through more joint training and planning, shared communications, and a recognition scheme.
Immigration Detention
Independent reviews(50)
Neurodivergence Task and Finish Group: report — Rec 3
Recommendation Three: Develop clear partnerships for supporting neurodivergent needs between education, health, and social care DfE and DHSC must act at pace to co-ordinate activity for improving service integration. Health, social care and education should be better integrated with clear local partnership arrangements. Educational Psychology services should be enabled to …
Health & Social Care
Carter NHS Productivity Review — Rec 11
Trust boards to work with NHS Improvement and NHS England to identify where there are quality and efficiency opportunities for better collaboration and coordination of their clinical services across their local health economies, so that they can better meet the clinical needs of the local community.
Health & Social Care
Carter NHS Productivity Review — Rec 10
DH, NHS England and NHS Improvement, working with local government representatives, to provide a strategy for trusts to ensure that patient care is focussed equally upon their recovery and how they can leave acute hospitals beds, or transfer to a suitable step down facility as soon as their clinical needs …
Health & Social Care
Carter NHS Productivity Review — Rec 4
Trusts should ensure their pathology and imaging departments achieve their benchmarks as agreed with NHS Improvement by April 2017, so that there is a consistent approach to the quality and cost of diagnostic services across the NHS. If benchmarks for pathology are unlikely to be achieved, trusts should have agreed …
Health & Social Care
Acheson Report — Rec 39.1
We recommend there should be a duty of partnership between the NHS Executive and regional government to ensure that effective local partnerships are established between health, local authorities and other agencies and that joint programmes to address health inequalities are in place and monitored.
Health & Social Care
Acheson Report — Rec 30
We RECOMMEND the further development of health and social services for older people, so that these services are accessible and distributed according to need.
Health & Social Care
Litchfield WCA Review Year 4 — Rec 27
The Department should carry out a full impact assessment on the feasibility of a DWP Decision Maker being collocated with the HCP undertaking a face-to-face assessment and either seeing the person making a claim jointly or separately.
Employment & Work
Litchfield WCA Review Year 4 — Rec 25
DWP continues to work with BMA to develop and co-design a revised electronic ESA113 with the aim of simplifying the process for GPs and improving the quality of evidence available.
Employment & Work
Litchfield WCA Review Year 4 — Rec 18
Build a better relationship between HCPs and Decision Makers to engender more team spirit and to help Decision Makers view HCPs as their trusted advisers.
Employment & Work
Willis Commission on Nursing 2012 — Rec 25
The regulation and inspection of the many organizations and settings where nursing education is delivered should be streamlined and better integrated to increase effectiveness and reduce the heavy audit burden. Healthcare and education regulators should work in close partnership, and take full heed of each other's findings. Their processes should …
Health & Social Care
Tooke MMC Inquiry — Rec 9
At a local level Trusts, Universities and the SHA (or equivalent) should forge functional links to optimise the health:education sector partnership. As key budget holders SHA Chief Executives should have the creation of collaborative links between local Health and Education providers as one of their key annual appraisal targets. Success …
Health & Social Care
Tooke MMC Inquiry — Rec 8
Recognising the interdependency of education, clinical service and research DH should strengthen its links not only within the Department and with NHS providers but also with other Government Departments, particularly the Department for Innovation, Universities and Skills and the Department of Business, Enterprise and Regulatory Reform. Ministers should receive annual …
Health & Social Care
Mental Health Taskforce 2016 — Rec 55
The CQC should work with Ofsted, Her Majesty’s Inspectorate of Constabulary and Her Majesty’s Inspectorate of Probation to undertake a Joint Targeted Area Inspection to assess how the health, education and social care systems are working together to improve children and young people’s mental health outcomes.
Health & Social Care
Mental Health Taskforce 2016 — Rec 29
To drive and scale improvements in integration, the Department of Health and relevant partners should ensure that future updates to the Better Care Fund include mental health and social work services.
Health & Social Care
Mental Health Taskforce 2016 — Rec 25
The MCP, PACS, UEC Vanguards and the Integrated Personalised Commissioning programme should be supported to ensure that the inclusion of payment for routine integrated care adequately reflects the mental health needs of people with long-term physical health conditions. Vanguard sites should also provide greater access to personal budgets for people …
Health & Social Care
Mental Health Taskforce 2016 — Rec 24
The Ministry of Justice, Home Office, Department of Health, NHS England and PHE should work together to develop a complete health and justice pathway to deliver integrated health and justice interventions in the least restrictive setting, appropriate to the crime which has been committed. Proposed mental health pathway and infrastructure …
Health & Social Care
Mental Health Taskforce 2016 — Rec 23
NHS England should lead a comprehensive programme of work to increase access to high quality care that prevents avoidable admissions and supports recovery for people of all ages who have severe mental health problems and significant risk or safety issues in the least restrictive setting, as close to home as …
Health & Social Care
Mental Health Taskforce 2016 — Rec 21
NHS England should ensure that people being supported in specialist older-age acute physical health services have access to liaison mental health teams – including expertise in the psychiatry of older adults – as part of their package of care, incentivised through the introduction of a new national Commissioning for Quality …
Health & Social Care
Mental Health Taskforce 2016 — Rec 20
PHE should prioritise ensuring that people with mental health problems who are at greater risk of poor physical health get access to prevention and screening programmes. This includes primary and secondary prevention through screening and NHS Health Checks, as well as interventions for physical activity, obesity, diabetes, heart disease, cancer …
Health & Social Care
Mental Health Taskforce 2016 — Rec 19
NHS England should undertake work to define a quantified national reduction in premature mortality among people with severe mental illness, and an operational plan to begin achieving it from 2017/18. NHS England should also lead work to ensure that by 2020/21, 280,000 more people living with severe mental illness have …
Health & Social Care
Mental Health Taskforce 2016 — Rec 18
By 2020/21, NHS England should invest to ensure that no acute hospital is without all-age mental health liaison services in emergency departments and inpatient wards, and at least 50 per cent of acute hospitals are meeting the ‘core 24’ service standard as a minimum.
Health & Social Care
Mental Health Taskforce 2016 — Rec 14
NHS England should invest to increase access to integrated evidence-based psychological therapies for an additional 600,000 adults with anxiety and depression each year by 2020/21 (resulting in at least 350,000 completing treatment), with a focus on people living with long-term physical health conditions and supporting 20,000 people into employment. There …
Health & Social Care
Mental Health Taskforce 2016 — Rec 13
By 2020/21, NHS England should complete work with ALB partners to develop and publish a clear and comprehensive set of care pathways, with accompanying quality standards and guidance, based on the timetable set out in this report. These standards should incorporate the relevant physical health care interventions and the principles …
Health & Social Care
Mental Health Taskforce 2016 — Rec 6
The Department of Health and the Department for Work and Pensions, working with NHS England and PHE, should identify how the £40 million innovation fund announced at the Spending Review and other investment streams should be used to support devolved areas to jointly commission more services that have been proven …
Health & Social Care
Mental Health Taskforce 2016 — Rec 4
The Cabinet Office should ensure that the new Life Chances Fund of up to £30 million for outcome-based interventions to tackle alcoholism and drug addiction through proven approaches requires local areas to demonstrate how they will integrate assessment, care and support for people with co-morbid substance misuse and mental health …
Health & Social Care
Mental Health Taskforce 2016 — Rec 2
PHE should develop a national Prevention Concordat programme that will support all Health and Wellbeing Boards (along with CCGs) to put in place updated Joint Strategic Needs Assessment (JSNA) and joint prevention plans that include mental health and co-morbid alcohol and drug misuse, parenting programmes, and housing, by no later …
Health & Social Care
Shape of Caring Review — Rec 32
HEE should work closely with the voluntary and independent sectors, and local government, and seek lay input to provide more integrated education and workforce planning across the system.
Health & Social Care
Harris Review: Deaths in Custody — Rec 30
A multidisciplinary and cross-departmental approach must be adopted to support young adults who have entered or are at risk of entering the Criminal Justice System. The Government Departments involved should be the Ministry of Justice, the Home Office, the Department of Health, Department for Innovation, Business and Skills, Department for …
Justice & Legal
Bubb Report — Rec 6
The Government and NHS England should require all local commissioners to follow a mandatory commissioning framework. The funding and responsibility for commissioning services for this group should be devolved as much as possible from NHS specialised commissioning to Clinical Commissioning Groups. Learning from the strengths (and weaknesses) of the Better …
Health & Social Care
Laming Review (Baby P) — Rec 30
All Children's Trusts should have sufficient multi-agency training in place to create a shared language and understanding of local referral procedures, assessment, information sharing and decision making across early years, schools, youth services, health, police and other services who work to protect children. A named child protection lead in each …
Other
Laming Review (Baby P) — Rec 25
Children's Trusts should ensure a named, and preferably co-located, representative from the police service, community paediatric specialist and health visitor are active partners within each children's social work department.
Other
Laming Review (Baby P) — Rec 22
The Department for Children, Schools and Families should establish statutory representation on Local Safeguarding Children Boards from schools, adult mental health and adult drug and alcohol services.
Other
Laming Review (Baby P) — Rec 21
The National Safeguarding Delivery Unit should urgently develop guidance on referral and assessment systems for children affected by domestic violence, adult mental health problems, and drugs and alcohol misuse using current best practice. This should be shared with local authorities, health and police with an expectation that the assessment of …
Other
Laming Review (Baby P) — Rec 20
All police, probation, adult mental health and adult drug and alcohol services should have well understood referral processes which prioritise the protection and well-being of children. These should include automatic referral where domestic violence or drug or alcohol abuse may put a child at risk of abuse or neglect.
Other
Wood Review of LSCBs — Rec 6
For government departments (Department of Health, Department for Education, the Department for Communities and Local Government and the Home Office) to provide a clear, joint statement explaining their commitment to multi-agency arrangements and explaining how all local partners will be supported and required to play a full and committed role.
Other
Wood Review of LSCBs — Rec 4
For new statutory arrangements to require health, local authorities and the police to make clear their leadership responsibility for multi-agency arrangements, to include the identification of a chief officer in each of the agencies to have responsibility and authority for ensuring full collaboration with those statutory arrangements.
Other
Henley Review of Cultural Education — Rec 2
Recommendation 2: Cross-departmental government co-operation — A new cross-Whitehall ministerial group on Cultural Education should be set up, under the chairmanship of the Culture Minister or an Education Minister.
Other
Wanless Review — Rec 3
Future reviews of this type should fully integrate modelling and analysis of health and social care. Indeed, it is for consideration whether a more immediate study is needed of the trends affecting social care (5.60).
Health & Social Care
Dilnot Commission — Rec 10
In reforming the funding of social care, the Government should review the scope for improving the integration of adult social care with other services in the wider care and support system. In particular, we believe it is important that there is improved integration of health and social care in order …
Health & Social Care
Black Review on Health and Work — Rec 10
The existing cross-Government structure should be strengthened to incorporate the relevant functions of those departments whose policies influence the health of Britain's working age population.
Health & Social Care
Black Review on Health and Work — Rec 9
An integrated approach to working-age health should be underpinned by: the inclusion of occupational health and vocational rehabilitation within mainstream healthcare; clear professional leadership from the occupational health and vocational rehabilitation communities to expand their remits and work with new partners in supporting the health of all working age people; …
Health & Social Care
Black Review on Health and Work — Rec 8
When appropriate models for the Fit for Work service are established, access to the service should be open to those on incapacity benefits and other out-of-work benefits. Government should fully integrate health support with employment and skills programmes, including mental health support where appropriate. Government should expand the provision of …
Health & Social Care
Black Review on Health and Work — Rec 1
Government, healthcare professionals, employers, trades unions and all with an interest in the health of the working age population should adopt a new approach to health and work in Britain based on the foundations laid out in this Review.
Health & Social Care
Allen Early Intervention Review (Part 1) — Rec 9
I recommend that the Department of Health and the Department for Education should work together with other partners and interests to produce within 18 months a seamless Foundation Years Plan from pregnancy to 5 years of age, which should be widely understood and disseminated in order to make the 0–5 …
Other
Tickell Review of the EYFS — Rec 15
I recommend strongly that the Government works with experts and services to test the feasibility of a single integrated review at age 2 to 2½.
Education
Munro Child Protection Review — Rec 8
The Government should work collaboratively with the Royal College of Paediatrics and Child Health, the Royal College of General Practitioners, local authorities and others to research the impact of health reorganisation on effective partnership arrangements and the ability to provide effective help for children who are suffering, or likely to …
Other
Corston Report — Rec 43
The management and care of self-harming women should be led by the NHS, either in an NHS resource or shared multi-disciplinary care in prison.
Justice & Legal
Corston Report — Rec 42
The NHS should provide health care services to police custody suites; in busy areas this will require a 24-hour presence and ideally be a registered mental health worker.
Justice & Legal
Corston Report — Rec 39
A DH minister must sit on the Inter-Departmental Ministerial Group for Women who offend or are at risk of offending and, at official level, DH must play a key part in the Women's Commission for this group. This must go wider than Prison Health and must include policy responsibility for …
Justice & Legal
Corston Report — Rec 36
All magistrates' courts, police stations, prisons and probation offices should have access to a court diversion/Criminal Justice Liaison and Diversion Scheme in order to access timely psychiatric assessment for women offenders suspected of having a mental disorder. These schemes should be integrated into mainstream services and have access to mental …
Justice & Legal
PHSO casework decisions(97)
P-003682 — Warrington and Halton Hospitals NHS Foundation Trust
Mrs R alleged poor handover of her late husband's gallbladder drain care and delayed removal, contributing to infections and his death.
NHS in England
Partly Upheld
Aug 2024
P-003080 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A complained his wife was prematurely discharged from hospital without a care package or explanation, causing stress that accelerated her deterioration and contributed to her subsequent death.
NHS in England
Oct 2024
P-003097 — Isle of Wight NHS Trust
Mrs H complained GPs neglected her mother's care and refused home visits post-cancer diagnosis. She also alleged cancer nurses left her mother in pain without a plan, believing these failings caused an avoidable death.
NHS in England
Oct 2024
P-003105 — Herefordshire and Worcestershire Integrated Care Board
The ICB wrongly removed his father-in-law’s fast track funding before his death, without following the correct process, causing financial stress and pressure to move care homes.
NHS in England
Nov 2024
P-003132 — North East London Integrated Care Board
The ICB allegedly delayed implementing Mrs A's personal health budget, under-commissioned care hours, and failed to reimburse family care or manage requests appropriately.
NHS in England
Partly Upheld
Nov 2024
P-004387 — County Durham and Darlington NHS Foundation Trust
Mrs O complained the District Nursing team neglected her mother's hygiene, failed to report concerns or symptoms of organ failure, and didn't collect samples, contributing to her mother's death.
NHS in England
Dec 2025
P-004740 — Hampshire Hospitals NHS Foundation Trust
Mr G's family complained about delayed cancer diagnosis due to GP telephone consultations, lack of Macmillan nurse referral, and restricted visiting and discharge to a care home at the Hospice.
NHS in England
Not Upheld
Jan 2026
P-001458 — Cambridgeshire and Peterborough Integrated Care Board
Mrs O complained NHS England’s review panel failed to recommend improvements for the CCG’s continuing healthcare processes, causing distress over unaddressed procedural errors.
NHS in England
Jul 2022
P-001513 — NHS England
Mrs A complained NHS England’s Independent Review Panel wrongly denied her mother continuing healthcare funding, questioning their assessment of her needs.
NHS in England
Aug 2022
P-001520 — Nottingham and Nottinghamshire Integrated Care Board
Mr P complained the ICB refused to retrospectively assess Mrs Y for continuing healthcare funding, alleging an incorrect checklist and missed assessment.
NHS in England
Aug 2022
P-001607 — Hull University Teaching Hospitals NHS Trust
Ms T complained about Hull University Teaching Hospitals NHS Trust discharging her mother, Mrs K, without a care plan or notifying her GP/social services. She also cited a fall at another trust and delayed notification.
NHS in England
Nov 2022
P-001691 — NHS England
Mrs O complained NHS England's IRP upheld the decision denying her mother CHC funding, causing stress and financial hardship for the family.
NHS in England
Nov 2022
P-001834 — NHS England
Dr U complained NHS England's IRP upheld his father's ineligibility for CHC funding, citing a panel without a clinician and misinterpretation of evidence.
NHS in England
Nov 2022
P-001696 — NHS England
Ms O complained about NHS England's Independent Review Panel decision denying her mother-in-law eligibility for continuing healthcare funding for a period, causing distress.
NHS in England
Dec 2022
P-001681 — NHS England Midlands and East
Mrs N complained NHS England decided not to hold an Independent Review Panel (IRP) regarding her mother's eligibility for continuing healthcare funding, preventing a potential refund.
NHS in England
Dec 2022
P-001744 — NHS England
Ms L complained NHS England's Independent Review Panel upheld a decision that her mother was ineligible for CHC funding, incorrectly assessing nutrition and medication needs.
NHS in England
Jan 2023
P-001716 — Birmingham and Solihull Integrated Care Board
Mrs W sought a retrospective Continuing Healthcare (CHC) review for her late mother-in-law's needs from January to July 2018, alleging the ICB would not complete it.
NHS in England
Jan 2023
P-001740 — NHS England
Mrs H alleged NHS England's Independent Review Panel incorrectly upheld a decision that her mother was ineligible for CHC funding from 2004-2011, due to errors in assessing her needs.
NHS in England
Jan 2023
P-001838 — Suffolk and North East Essex Integrated Care Board
Mr O complained the ICB improperly handled Mrs O's CHC funding eligibility, refusing a full assessment and not involving him, leading to significant care home fees.
NHS in England
Jan 2023
P-001787 — Humber and North Yorkshire Integrated Care Board
A legal firm complained the ICB refused to complete a checklist/DST for Mrs A's Continuing Healthcare, denied an FNC appeal, and refused a previously unassessed period of care assessment.
NHS in England
Feb 2023
P-002013 — Bedfordshire Hospitals NHS Foundation Trust
Mrs C complained the Trust discharged Mr J while he was clinically dehydrated and immobile, leading to distress and readmission. She also cited poor communication of his condition to the family.
NHS in England
Partly Upheld
Jun 2023
P-003858 — Black Country Integrated Care Board
The ICB failed to fully assess her mother's needs for CHC funding, disadvantaging her estate by not fully considering evidence.
NHS in England
Sep 2023
P-002377 — Barts Health NHS Trust
Mr E complained a Trust failed to properly assess and treat his mother, discharging her unfit, leading to an undiagnosed infection, broken back, and ultimately her death.
NHS in England
Dec 2023
P-002695 — Barking, Havering and Redbridge University Hospitals NHS Trust
Mrs N complained the Trust incorrectly made a safeguarding referral for her son and that Practices A and B provided inadequate care, impacting his treatment.
NHS in England
Jun 2024
P-002832 — United Lincolnshire Hospitals NHS Trust
Ms O complained the Trust poorly communicated, failed to provide an appropriate diet, delayed rehabilitation, and poorly coordinated her brother's discharge, which she said contributed to his death. She also cited poor ED care.
NHS in England
Upheld
Jul 2024
P-002795 — Cornwall and Isles of Scilly Integrated Care Board
Mr O complained the ICB wrongly declined his mother's continuing healthcare checklist, disputing issues with its completion and consent, resulting in financial impact.
NHS in England
Jul 2024
P-002846 — NHS England
Mrs A complained NHS England's review of her father's continuing healthcare eligibility was flawed, disagreeing with domain weightings and the assessment process.
NHS in England
Aug 2024
P-003170 — NHS England
Mrs O complained NHS England's independent review panel wrongly upheld the ICB's decision that her daughter was ineligible for continuing healthcare funding, despite her increasing needs.
NHS in England
Nov 2024
P-003178 — NHS England
Mr N complained NHS England's independent review panel wrongly upheld the ICB's decision that his late mother was ineligible for continuing healthcare funding, causing financial impact.
NHS in England
Nov 2024
P-003407 — Cheshire and Merseyside Integrated Care Board
Mrs B complained the ICB delayed applying COVID-19 legislation for her mother's care funding and poorly handled their complaint, causing distress and delayed closure.
NHS in England
Nov 2024
P-003201 — Greater Manchester Integrated Care Partnership
Mrs M complains the ICB improperly refused a full continuing healthcare funding assessment for her mother, despite increased needs and not following national guidelines.
NHS in England
Upheld
Dec 2024
P-003181 — A practice in the Newham area
Mr B complained staff failed to monitor his father, who pulled out his oxygen tube, leading to low oxygen, infections, pain, and potentially hastening his death.
NHS in England
Dec 2024
P-003316 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr and Mrs D complained H&W Trust failed to provide appropriate home care after Mr F's hospital discharges, and WAH Trust discharged him without an adequate care plan. They alleged this led to neglect, sepsis, and his death.
NHS in England
Partly Upheld
Feb 2025
P-003349 — Mid and South Essex NHS Foundation Trust
Staff allegedly failed to provide adequate nutrition/hydration, ensure physiotherapy, and discharged Mr I when he was unfit, leading to his death after nine days.
NHS in England
Partly Upheld
Feb 2025
P-003478 — Midlands Partnership University NHS Foundation Trust
Ms A complained the Trust inappropriately placed her mother on end-of-life care, withdrew treatment and food, used a syringe driver unnecessarily, and communicated poorly, leading to her mother's death.
NHS in England
Apr 2025
P-003479 — Isle of Wight NHS Trust
Mrs F complained Trust A failed to inform her of her husband's sepsis and transferred him without her consent. She also stated Trust B provided inappropriate care and delayed informing her of his death.
NHS in England
Apr 2025
P-003543 — University Hospitals of North Midlands NHS Trust
Ms A alleged unsafe discharge with an open neck wound and no district nursing referral, causing disfigurement, a back hump, and severe depression.
NHS in England
May 2025
P-003576 — Nottingham University Hospitals NHS Trust
Mr B complained his wife was wrongly discharged with a brain aneurysm, improperly moved to a low dependency ward, and received poor communication, leading to her death.
NHS in England
May 2025
P-003619 — West Yorkshire Integrated Care Board
Ms P complained the ICB provided inadequate care funding and the Trust's insufficient respiratory care and incorrect medication, which she believed contributed to her mother's death.
NHS in England
Partly Upheld
Jun 2025
P-003787 — Norfolk and Waveney Integrated Care Board
Mr and Mrs A complained that Mrs A, a holidaymaker, could not access primary eye care in Norfolk, believing the CUES contract excluded non-residents. This caused them distress.
NHS in England
Aug 2025
P-003797 — Greater Manchester Integrated Care Partnership
Mrs C complained the ICB failed to respond to call-back requests, didn't inform her about her father's changing care needs, and failed to consider her ability to travel to visit him.
NHS in England
Aug 2025
P-003796 — North East and North Cumbria Integrated Care Board
Mrs B complained the ICB reduced her sister's continuing healthcare package without proper rationale and failed to provide meeting minutes or address the impact of her increased caring responsibilities.
NHS in England
Partly Upheld
Aug 2025
P-003926 — NHS England Midlands and East
Mrs O complained NHS England's independent review panel did not properly consider her mother's needs for continuing healthcare funding, nor procedural errors by the local integrated care board.
NHS in England
Sep 2025
P-004005 — NHS England
Mr K complained NHS England's independent review panel wrongly upheld a decision that his mother was not eligible for NHS continuing healthcare (CHC) funding, due to improper consideration of needs and procedural mistakes.
NHS in England
Sep 2025
P-004086 — University Hospitals Sussex NHS Foundation Trust
The Trust provided inadequate care to her husband, including minimal senior review, inappropriate medication, poor pain management, and a fall due to lack of supervision, contributing to his death.
NHS in England
Partly Upheld
Sep 2025
P-004168 — Midlands Partnership University NHS Foundation Trust
Miss R complained about inadequate pressure sore treatment by district nurses, inappropriate discharge, insufficient pain relief from GPs, and poor safeguarding management concerning her father.
NHS in England
Partly Upheld
Oct 2025
P-004126 — Lincolnshire Partnership NHS Foundation Trust
Mrs I complained about the care and treatment provided to her son by multiple NHS Trusts from 2011 to 2023, leading up to his death.
NHS in England
Oct 2025
P-004222 — Nottingham and Nottinghamshire Integrated Care Board
Mrs A complained Nottingham and Nottinghamshire Integrated Care Board incorrectly refused a full continuing healthcare funding assessment and a retrospective review for her mother.
NHS in England
Nov 2025
P-004277 — An independent provider in the City of Plymouth …
Mr R complained the Provider failed to appropriately action a catheter referral, causing an infection, discomfort, and forcing him to seek urgent care elsewhere.
NHS in England
Nov 2025
P-001085 — Southend University Hospital NHS Foundation Trust
Mrs A complained about delayed sepsis treatment, insufficient contact regarding her husband's deterioration, and a lack of discussion about a do-not-resuscitate decision.
NHS in England
Upheld
Jul 2021
LGO / SPSO decisions(390)
18-006-752d — NHS West Yorkshire Health and Care Partnership Integrated …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
18-006-752c — NHS West Yorkshire Health and Care Partnership Integrated …
Summary: We found fault by the Council, Trust and ICB in terms of the care and support they provided to a man with complex needs. We recommend these organisations carry out a thorough reassessment of his needs and put in place a comprehensive care plan that sets out how they …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-006-652a — NHS South West London ICB (21 006 652a)
Summary: Mrs B complains about the ICB’s funding of her disabled son F’s care. She says the ICB did not fund enough care hours, so the Council paid for extra overnight care which meant it would not increase the respite hours for her and her son. Mrs B says this …
LGO (Local Government & …
Health
Upheld
Dec 2022
22-009-742 — West Northamptonshire Council
Summary: Miss D complained about the lack of mental health and social care provided to her son, Mr B, when he was discharged from hospital. She said this led to a lack of joint working between the Council, the Trust and the Integrated Care Board (ICB). She said they did …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2024
23-008-538 — Oxfordshire County Council
Summary: Ms X complained about Oxfordshire County Council, Oxford Health NHS Foundation Trust, and NHS Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board. She complained about faults relating to aftercare under section 117 of the Mental Health Act 1983. We have upheld Ms X’s complaints about discharge, assessment, care planning …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
24-014-250 — London Borough of Wandsworth
Summary: Mrs X complained the Council failed to act when she contacted it with concerns about her late brother’s care and it was difficult to get in contact with anyone. She also complained the care home the Council commissioned failed to get an air mattress for her late brother before …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
25-005-077 — London Borough of Hammersmith & Fulham
We find fault by West London NHS Trust and London Borough of Hammersmith and Fulham in terms of their delivery of aftercare services to which Mr X was entitled under section 117 of the Mental Health Act 1983. This fault caused Mr X uncertainty and distress. The Trust and Council …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2026
25-008-975a — NHS Hampshire and Isle of Wight ICB (25 …
Mr X complained about repeated failures of Hampshire County Council and NHS Hampshire and Isle of Wight Integrated Care Board to work together. He complained this caused: a prolonged delay in discharging his wife from hospital; and, his wife to be left without funding for necessary night-time care. We found …
LGO (Local Government & …
Health
Upheld
Feb 2026
PSOW-202201680 — Cardiff and Vale University Health Board
Ms X complained that she was encountering concerns with her mental health team and that although she has put complaints forward to the Health Board, she is yet to receive a response. The Ombudsman was concerned that Ms X had yet to receive a response from the Health Board and …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202502982 — Aneurin Bevan University Health Board
Mr H complained that Aneurin Bevan University Health Board failed to respond to complaints submitted in December 2023 and September 2024. He also complained that it failed to communicate directly with his advocate. The Ombudsman found that there was a significant delay with the Health Board issuing the complaint responses. …
PSOW (Public Services Om…
Health
Sep 2025
20-005-428 — London Borough of Brent
Summary: Miss Y complained on behalf of her mother, Mrs X. She said the Council failed to effectively communicate with its contractor to provide her mother with a high back chair to meet her needs. Miss Y said that this resulted in Mrs X using an unsafe chair for longer …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-002-940 — Suffolk County Council
Summary: Mr X complained the Council changed and suspended his son, Mr Y’s, direct payments during 2020 without adequate communication or explanation. The Council was at fault for failing to pay Mr Y’s respite payment since 2020 despite it being an assessed care and support need. The Council agreed to …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
20-010-965 — Devon County Council
Summary: Ms X complains the Council delayed in reviewing Ms Y’s care plan following an increase in the hourly rate of her care provider. The Council is at fault as it delayed in carrying out a review of Ms X’s care plan and making a decision on whether to increase …
LGO (Local Government & …
Adult Care Services
Upheld
Feb 2022
21-006-660 — Essex County Council
Summary: Mr X complained the Council failed to fix a specially adapted toilet in his home after a care worker broke it several months ago. He said this situation has caused him stress and inconvenience. there was fault in the Council’s failure to source a plumber to visit Mr X’s …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-003-302 — Hampshire County Council
Summary: Mr R, representing his daughter, Ms G, said the Council was at fault for delays in providing suitable care for Ms G, and for being unhelpful and obstructive in the way it monitored spending of direct payments made to fund that care. He also said it was responsible for …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-003-925 — Peterborough City Council
Summary: We found fault with the Trust; it did not allocate Mr Q a new care coordinator, did not conduct a S117 review or formally discharge him, and it was not clear with Mr P during the complaints process. We also found the Council did not understand the care package …
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
22-004-321 — City of Doncaster Council
Summary: We will not investigate this complaint about the Council’s handling of Mr X’s direct payments. This is because there is insufficient evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-005-829a — Warrington & Halton Hospitals NHS Foundation Trust (21 …
Summary: Mrs B complains about what happened when her father, Mr C, was discharged from hospital after attending with a fractured collarbone, and about arrangements for putting a care package in place. We found the Trust was at fault for the lack of information given to Mr C and his …
LGO (Local Government & …
Health
Upheld
Sep 2022
22-007-883 — Leicester City Council
Summary: We will not investigate this complaint the Council delayed in arranging for Mr X’s property to be decluttered. That is because we are satisfied with the action the Council proposes to take.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
21-013-224b — NHS Lincolnshire ICB (21 013 224b)
Summary: Mrs B complained about the health and social care support provided by the Council and the NHS Trust after she removed her late husband, Mr B, from a respite placement and took him home. She also complained about the way the former Clinical Commissioning Group (CCG and now Integrated …
LGO (Local Government & …
Health
Upheld
Nov 2022
21-013-224a — Lincolnshire Community Health Services (21 013 224a)
Summary: Mrs B complained about the health and social care support provided by the Council and the NHS Trust after she removed her late husband, Mr B, from a respite placement and took him home. She also complained about the way the former Clinical Commissioning Group (CCG and now Integrated …
LGO (Local Government & …
Health
Upheld
Nov 2022
23-002-530a — NHS Greater Manchester ICB (23 002 530a)
Summary: We investigated a complaint about the care provided to Mrs A’s late brother, Mr B. We found fault with the Integrated Care Board who did not respond to Mrs A’s complaints in a timely manner, made a derogatory comment about her and interpreted her words rather than seeking clarification. …
LGO (Local Government & …
Health
Upheld
Apr 2024
23-010-321 — London Borough of Hillingdon
Summary: The Council’s failure to work in a joined-up way across its repairs and adaptations teams was fault. It should not have closed Ms Y’s adaptations case when it did. The Council has agreed to apologise, write to Ms Y about her adaptations, work with the repairs service, make a …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-014-971 — Birmingham City Council
Summary: Mrs X complained that although her mother, Mrs Y should receive assisted collections the Council has repeatedly failed to collect her household waste and recycling. Mrs X also complains that when the Council does empty Mrs Y’s bin, it does not return it correctly to Mrs Y’s property. The …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2024
23-014-013 — Trafford Council
Summary: Mr X complained the Council failed to reduce Ms Y’s care package after it was temporarily increased. The Council was at fault for increasing the package without telling Ms Y, in how it decided to increase the package, for delay reviewing it and delay progressing obtaining a hoist for …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2024
22-017-137 — City of Bradford Metropolitan District Council
Summary: Ms Y complained about failings during her father’s discharge planning, and delays in the repatriation of her mother. We have found fault by the Council for failings in discharge planning. We have also found fault by Bradford Trust and Chesterfield Trust for failings in the repatriation process. These faults …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2024
23-014-449 — London Borough of Newham
Summary: Ms X complained about the way the Council handled her request for housing assistance and how it responded to her concerns about the condition of her property. As a result, Ms X lived in a property with repair issues and this impacted her health. We have found the Council …
LGO (Local Government & …
Housing
Upheld
Aug 2024
24-000-008 — London Borough of Ealing
Summary: Mrs Y complained the Council failed to arrange suitable care for her mother, Mrs X, when she was discharged from hospital. Mrs Y said this meant she and her sister, Ms W, had to provide the care instead. The Council was at fault for delay in arranging a new …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
24-000-025 — London Borough of Newham
Summary: We upheld Ms X’s complaint. There was a delay in assessing her son Mr Y’s social care needs and her need for support in her caring role. There was also a delay in agreeing funding for a day centre placement. The outcome and recommendations of assessments were confusing. The …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2024
23-017-874a — Norfolk & Norwich University Hospitals NHS Foundation Trust …
Summary: We found fault with the care and support provided to Mr Y by the Council as it failed to properly assess his needs in the community. This caused Mr Y’s daughter, Mrs X, significant frustration and distress. The Council will apologise to Mrs X and pay her a financial …
LGO (Local Government & …
Health
Not Upheld
Sep 2024
23-019-435 — West Sussex County Council
Summary: Mrs X complained about the Council’s decision to remove transport funding from Mr X’s care package and about its complaints handling. We found fault in the Council’s decision making and complaint handling which caused Mrs X and her family distress and frustration. To put matters right, the Council agreed …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2024
24-018-121 — Dorset Council
Summary: We will not investigate this complaint about the Council’s actions during the assessment for NHS funding for adult care. The Council’s actions do not cause the claimed injustice of a failure to award Continuing Healthcare funding. That is an NHS decision, and is not an outcome the Council nor …
LGO (Local Government & …
Adult Care Services
Apr 2025
24-004-911 — Somerset Council
Summary: Mr X complained about the Council’s handling of his son, Mr Y’s, case after he made a referral to Adult Social Care Services in March 2023. He said Mr Y has had seven allocated social workers since March 2023 which delayed Mr Y getting the relevant care assessments and …
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-002-649 — Birmingham City Council
Summary: Mr X complained about delays in the Council completing adaptations to his home following an Occupational Therapy assessment in January 2023. Mr X said this caused him significant distress and he suffered physically. There was fault in the way the Council delayed completing the work to Mr X’s home, …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
23-013-609b — Royal Free London NHS Foundation Trust - North …
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …
LGO (Local Government & …
Health
Upheld
Jun 2025
23-013-609a — Royal Free London NHS Foundation Trust - North …
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …
LGO (Local Government & …
Health
Upheld
Jun 2025
24-016-885 — Kirklees Metropolitan Borough Council
Summary: Mr X complained about the Council’s decision to end direct payments to his relative Mr Z. There was no fault in the way the Council reached its decision. There was fault in its communication with Mr Z and in its failure to ensure there was a proper coordinated handover …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2025
24-009-941a — Somerset NHS Foundation Trust - Musgrove Park Hospital …
Summary: Mrs A complained about the care Somerset Council and Somerset NHS Foundation Trust provided to her daughter, Miss B, before her death. She complains the Council and Trust refused to provide funding for 24-hour care which Miss B needed, could not find Miss B a suitable care agency and …
LGO (Local Government & …
Health
Not Upheld
Oct 2025
24-009-941 — Somerset Council
Summary: Mrs A complained about the care Somerset Council and Somerset NHS Foundation Trust provided to her daughter, Miss B, before her death. She complains the Council and Trust refused to provide funding for 24-hour care which Miss B needed, could not find Miss B a suitable care agency and …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2025
25-009-306 — Sandwell Metropolitan Borough Council
Summary: We will not investigate this complaint about the care and support the Council provided to the complainant’s neighbour following their discharge from hospital. There is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Adult Care Services
Nov 2025
24-010-479 — Gravesham Borough Council
Summary: We cannot investigate some of Ms X’s complaints about anti-social behaviour from a neighbour as they relate to the Council’s role as a social landlord and the law says we cannot investigate. We will not investigate other elements of Ms X’s complaint because an investigation is unlikely to achieve …
LGO (Local Government & …
Environment And Regulation
Nov 2024
201503727 — Falkirk Council
Ms C's mother was admitted to a care home and the council provided Ms C's family with a breakdown of the charges for the care home and invoiced the family accordingly. Following an admission to hospital, Ms C's mother returned to the care home, however, Ms C's family received no …
SPSO (Scottish Public Se…
Local Government
Upheld
Mar 2016
25-006-991a — East London NHS Foundation Trust (25 006 991a)
Summary: Mr C complains the Council and Trust failed to provide him with suitable care, respond to calls, and support him with his direct payments. We will not investigate the complaint as some of the complaints are late. The Council has acted to remedy other complaints and complete a new …
LGO (Local Government & …
Health
Dec 2025
201809536 — Argyll and Bute Health and Social Care Partnership
Mr and Mrs C complained about the partnership's management of their adult son's care (Mr A). Mr A's care was managed by the partnership for a number of years. The partnership moved Mr A's care away from his family base when they came to the view that the level of …
SPSO (Scottish Public Se…
Health and Social Care
Partly Upheld
Mar 2020
202302196 — Orkney NHS Board
C complained that the board failed to provide reasonable physiotherapy care and treatment to their child (A) and failed to maintain reasonable clinical records. We took independent advice from a physiotherapist. We found that some aspects of A’s care were reasonable, particularly in relation to ongoing treatment at school, and …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2024
PSOW-202105742 — Betsi Cadwaladr University Health Board
Mrs J complained about the actions of the Learning Disability Team (“the LD Team”) of the Health Board in response to her request to provide assistance to move her sister, Miss M, from the upstairs of her home to a new home with Mrs J and her family in April …
PSOW (Public Services Om…
Health
Upheld
Dec 2022
PSOW-202101741 — Aneurin Bevan University Health Board
Mr A’s concerns related to the treatment and care of his late wife, Mrs A. He complained about his wife’s care during her inpatient admission at the Royal Gwent Hospital (“the Hospital”) between 15 March and 31 March 2020, the accuracy of his wife’s clinical records and the Health Board’s …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202307690 — Aneurin Bevan University Health Board
Ms G complained that Aneurin Bevan University Health Board had failed to respond to the complaint she had made to it in May 2023. The Ombudsman found that there was a delay in the Health Board responding to Ms G’s complaint, which the Ombudsman said caused frustration to Ms G. …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202307628 — A Dental Practice in the area of Swansea …
Miss X complained that a Dental Practice in the area of Swansea Bay University Health Board had failed to respond to her complaint about being deregistered from the Practice. Miss X had made her complaint in September 2023. The Ombudsman found that the Practice had failed to respond to Miss …
PSOW (Public Services Om…
Health
Jan 2024
PSOW-202307183 — Betsi Cadwaladr University Health Board
Mrs A complained that Betsi Cadwaladr University Health Board failed to provide a response to her complaint until her MP raised the concerns on her behalf. The Ombudsman found that the Health Board had initially responded to Mrs A’s concerns informally. However, following the same concerns being raised by Mrs …
PSOW (Public Services Om…
Health
Jan 2024
Domestic Homicide Reviews(1432)— showing 50 strongest matches
Bromley — recommendation 4.5.3
The MPS and Probation Services (NPS and CRC) review how closer work between the police CSUs and Probation could strengthen the management of domestic abuse cases.
Metropolitan Police Service | National Probation …
Metropolitan Police Service
Bromley — recommendation 4.5.1
The Home Office to consider further developing, in partnership with the Department of Health, a minimum standard of reporting and response in all health settings, i.e. beyond the NICE guidance to ensure better support for victims of domestic violence.
Home Office | Department of Health
Home Office
Bromley — recommendation 4.4.1
The local domestic abuse partnership must review its membership, structure and processes to ensure the delivery of a coordinated response to domestic abuse and report directly to the Community Safety Partnership and local Children and Adult Safeguarding Boards.
Bromley Community Safety Partnership | Bromley …
Kent — recommendation 8
More effective multiagency working through stronger risk assessments and training for practitioners will identify and support, in a non-stigmatising way, vulnerable people who are experiencing alcohol harm. This can be achieved by a multi-agency seminar with key partners to discuss and explore alternative strategies and best practice to tackle this …
KCC Public Health
Kent — recommendation 7
The Dual Diagnosis assessment process should be reviewed, and a Multi-Agency Pathway developed (in conjunction with substance abuse experts).
KMPT | Forward Trust
Kent and Medway NHS …
Kent — recommendation 6
The current referral pathway for Alcohol Treatment Requirement/Drug Rehabilitation Requirement needs to be reviewed. This will include Information Sharing Agreements with key Statutory Partners to obtain information and intelligence to manage risk assessments and facilitate Safeguarding protection for service users’ families.
Forward Trust
The Forward Trust
Kent — recommendation 1
Agencies should be aware which “Front Door” Service should be their first point of contact. ARMS and SPoA need to circulate their referral criteria.
KCC ASC | KMPT
Kent and Medway NHS …
Lincoln — recommendation Recommendation 3 i)
The Lincolnshire Safeguarding Children Partnership must seek assurance from Children Social Care that they have made changes to the local Child in Need processes which makes them more inclusive and that all relevant agencies, including those providing services to adults, are included more consistently in the process and meetings. This …
Lincolnshire Safeguarding Children Partnership | Children …
Lincoln — recommendation 1
Whilst learning has been identified in terms of how practitioner practice could be improved in terms of multiagency working; it remains unclear as to why Probation services were not involved in the Child in Need process or whether the concerns of the supported housing provider were shared and acted on. …
Probation Service
Probation Service
Lincoln — recommendation ii)
Children’s services staff to be supported to ensure attendance and contributions from all relevant agencies at multi-agency meetings and in children’s plans.
Lincolnshire County Council Children Services
Cheltenham — recommendation GASC.7
Multi-agency reviews to be requested by ASC if situation escalates/changes.
Gloucestershire Adult Social Care
Doncaster — recommendation 5
That Safer Stronger Doncaster Partnership reviews the multi- agency response to victim engagement during DVDS and criminal investigations.
Safer Stronger Doncaster Partnership
West Lancashire — recommendation 10
WLCSP shares this learning with the Office of the Police and Crime Commissioner and health Sector commissioning services in Lancashire, including the NHS Integrated Care Board, so that they may explore the feasibility of developing an operating procedure to allow the co-location of these services within hospital based IDVA services
Office of the Police and Crime …
NHS Lancashire and South …
West Lancashire — recommendation 4
WLCSP to share the 'suicidal ideation' learning opportunity for suicide prevention with all agencies that have formed part of this Panel, Lancashire and South Cumbria Health and Care Partnership: Start the conversation (healthierlsc.co.uk)
West Lancashire Community Safety Partnership
Manchester — recommendation 8
The Manchester CSP supports the designated NHS safeguarding teams to liaise with the medicines optimisation teams and GMMH NHS Trust to support best practice across Greater Manchester, and work with MIC to circulate a clear description of best practice to GPs when they are working with patients who transfer from …
Manchester Community Safety Partnership | NHS …
Greater Manchester Mental Health …
Doncaster — recommendation 1
Where an individual is in receipt of secondary mental health services and moves to an area outside of the Trust boundaries, they should be referred to local services by the original Trust
Rotherham Doncaster & South Humber NHS …
Rotherham Doncaster and South …
Norfolk — recommendation 3
That the Ministry of Justice and HM Prison Service establish that all commissioned Prison Health Services are required to provide a timely written discharge report with a transfer of notes to community services and primary care prior to or on release from custody. There should also be a requirement that …
Ministry of Justice | HM Prison …
Ministry of Justice
Gloucester — recommendation 2
Probation services to develop a pathway with P3 to effectively challenge each other’s risk assessments when looking at a service user’s suitability for accommodation. This may prevent delays in the system for vulnerable service users. The first step in this process will be to engage with the Gloucestershire Reducing Reoffending …
BGSW CRC
Gloucester — recommendation 6
In situations where parents or carers are disengaging and are at risk of being denied services which would impact on their capacity to provide care to their children, social workers should highlight concerns with the relevant agency to inform a multiagency response including the use of multi-agency escalation policy as …
Gloucestershire Children’s Social Care
Gloucester — recommendation 5
GCSC and housing providers to regularly liaise in situations where there are child safeguarding concerns for unborn children to ensure that the impact on a tenancy or housing provision is understood, assessed and an appropriate contingency is in place.
Gloucestershire Children’s Social Care
Gloucester — recommendation 13
Gloucestershire MARAC review its current capacity against the expected volume of cases for the population it covers and look to increase capacity, particularly around decision-making. An additional MARAC decision-maker would increase capacity and resilience in the model.
Gloucestershire MARAC
Gloucester — recommendation 12
Gloucestershire MARAC to ensure decisions around whether to hold a formal or virtual MARAC are made on the basis outlined in the Gloucestershire MARAC Protocol and that virtual MARACs achieve the same outcomes regarding the sharing of information and bespoke multi-agency action plans for victims of abuse. Annual dip sampling …
Gloucestershire MARAC
Gloucester — recommendation 11
Gloucestershire MARAC agencies to review their policies and practices regarding risks to staff from clients and to consider how they share such information with other agencies. MARAC Steering Group to consider how the MARAC system can assist in the distribution of such risk information to partner agencies.
Gloucestershire MARAC agencies | MARAC Steering …
Gloucester — recommendation 9
GDASS and Nelson Trust to work more closely together, such as GDASS providing a drop-in service at the Nelson Trust Women’s Centre. GDASS to advise NT staff when they are supporting women who are the victims of domestic abuse.
Gloucestershire Domestic Abuse Support Service | …
Gloucester — recommendation 8
GCCH and Gloucestershire local authority strategic housing officers to work with Registered Housing Providers (RPs) to create a common protocol when housing households that include those who may be perpetrators, and victims of domestic abuse. The protocol should prioritise victims’ safety and demonstrate an understanding of the dynamics of domestic …
Gloucester City Council Housing | Gloucestershire …
Gloucestershire County Council
Gloucester — recommendation 5
GCSC to work with GDASS to develop guidance for child protection conference chairs to ensure that the dynamics of domestic abuse inform the deliberations.
Gloucestershire Children’s Social Care | Gloucestershire …
Gloucester — recommendation 2
Safer Gloucestershire to create a multi-agency working group to develop a care pathway for those with multiple disadvantage or complex needs, and to advise partner agencies on training their staff to respond to such clients, including trauma-informed practice.
Safer Gloucestershire
Gloucester — recommendation 1
Gloucestershire Criminal Justice Board to use this case to review with multi-agency partners how people in Scott’s situation – in and out of prison, with mental ill health, using substances, a history of homelessness and domestic abuse -- get identified and supported by the system, including getting consistent proactive support …
Gloucestershire Criminal Justice Board
Gloucester — recommendation 1
The National Criminal Justice Board use this case to review with multi-agency partners how people in Scott’s situation – in and out of prison, with mental ill health, using substances, a history of homelessness and domestic abuse -- get identified and supported by the system, including getting consistent proactive support …
National Criminal Justice Board
Kent — recommendation 9
The MARAC process requires a review to make sure that it is more meaningful. Evidence has shown that because numerous victims are discussed within the one meeting there are often times when individual agencies who are relevant are not identified and invited. A more robust process needs to take place …
Kent and Medway MARAC Steering Group
Kent — recommendation 6
Kent and Medway CCG to continue to develop the work with GPs surrounding attendance at MARACs and the importance of information sharing. Consideration to be given to the creation of the role of a MARAC liaison nurse’s role for general practice to allow for a more informed and effective decision …
Kent and Medway ICB
NHS Kent and Medway …
Kent — recommendation 3b
Although domestic abuse is mentioned as a risk factor within the national suicide strategy, neither suicide nor suicidality are mentioned within the Government’s most recent violence against women and girls (VAWG) or domestic abuse strategy. It seems clear that any meaningful integration of policy or practice across both spheres is …
Home Office
Home Office
Wokingham — recommendation 3
We recommend that the local NHS and Adult Social Care engage with representatives of independent and voluntary sector organisations to agree protocols for ongoing communication and involvement in multi-agency care planning that will encourage more effective joint working across sectors.
Wokingham Borough Council | Berkshire West …
Royal Berkshire NHS Foundation …
Wokingham — recommendation R4
Healthcare professionals should advise the adult social care team so that a Care Act assessment can be offered or completed to determine level and appropriateness of care input required regardless of funding arrangements for care and support needs for patients in the community, especially when a patient lacks capacity to …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Wokingham — recommendation R2
That an interagency pathway and pathway document should be developed with the support of patient representatives e.g. Alzheimer’s Society so that early assessment and referral taking into account the needs of the carer and the vulnerable adult and recognising the emerging vulnerability of the carer is developed
Royal Berkshire NHS Foundation Trust
Royal Berkshire NHS Foundation …
Wokingham — recommendation R3
Develop joint working arrangements for couples with this domestic risk profile.
Wokingham Borough Council | Berkshire Healthcare …
Berkshire Healthcare NHS Foundation …
Doncaster — recommendation 19.2.10
Embedding of structured links between parishes and local agencies who respond to domestic abuse.
Sheffield Diocese
Cheshire West and Chester — recommendation 6
Cheshire Police and National Probation Service to work together to ensure the provision of call out information (VPA) to inform Court reports
Cheshire Constabulary | National Probation Service
Cheshire Constabulary
Cheshire West and Chester — recommendation 2
Statutory partners to provide reassurance to the CSP that Professionals seek to triangulate information which may help them to inform a more holistic assessment of a patient/client which is inclusive of information available from family and partner agencies.
Cheshire West and Chester Community Safety …
Kent — recommendation 12
When offenders subject to statutory supervision are related, professionals with offender management responsibility must work collaboratively in order to build a holistic view of the family to inform the assessment and management of risk.
NPS | YOS
National Probation Service
Kent — recommendation 5
To facilitate information exchange, East Kent Housing to attend formal and minuted Tasking and Coordinating Meetings held by the Thanet Community Safety Unit.
East Kent Housing | Thanet District …
Thanet District Council
Walsall — recommendation 2
Learning from DHR7 around the ‘seven domains of harm’ associated with problem gambling, and the need to be professionally curious when encountering an individual exhibiting co-morbidity of problem gambling, substance misuse and mental health issues, is to be the subject of a multi-agency learning event in Walsall. Attendees to include …
Walsall Council
Walsall Council
Derby — recommendation 7
A coordinated and collaborative approach should be the aspiration of mental health services including crisis, community and hospital teams, across areas and trusts, with other relevant organisations to enable seamless continuity of care focused on the needs of individuals, with specific consideration of history and current circumstances particularly when transfer …
Mental health services
Kent — recommendation 3
That a lead agency be identified in complex cases and an appropriate person from that agency will hold a leadership role in managing a case.
Kent and Medway ICB | KCC …
NHS Kent and Medway …
Swindon — recommendation 30
Swindon Women’s Aid require a structured Referral Pathway Protocol for those occasions when a survivor of domestic abuse moves to another service provider.
Swindon Women’s Aid
Lincoln — recommendation 14
LSAB should invite agencies to consider: • The importance of developing a formal multi-agency approach around “think family” to take a more holistic approach to the identification and management of risk, ensuring patterns of behaviour can be identified and incidents are not dealt with in isolation and that complex family …
LSAB | agencies
Lincoln — recommendation 5
Professionals should always consider whether decisions about safeguarding responses in complex cases, such as this, need to be carried out in a multi-disciplinary way. This did not happen for the victim and there is currently no formal process to allow this to happen. • The LSAB will need to consider …
LSAB
Coventry — recommendation 9
Coventry Safeguarding Adult Board should ensure that the multi-agency dual diagnosis policy (which is out of date) is refreshed between CGL, Coventry and Warwickshire Partnership NHS Trust and other mental health providers and overseen by commissioners of those services.
Coventry Safeguarding Adult Board
Coventry — recommendation 7
Coventry Police and Crime Board to assess whether there is sufficient multi-agency support and co-ordination for the resettlement of homeless individuals with multiple and complex needs.
Coventry Police and Crime Board
Kent — recommendation 1
Secure Units and other similar establishments should ensure that there is a process of effective communication between them, the Police and other appropriate agencies regarding reporting assaults in their establishments. This must include the local authority where assaults occur in hospitals between patients.
NHS England
NHS England