Poor prevention and early intervention
Over-reliance on hospital discharge solutions rather than prioritising prevention and early intervention strategies in health and social care.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
11 inquiry recs
92 PFD reports
417 committee recs
9 HSSIB recs
34 CQC actions
18 HMICFRS recs
4 NAO recs
1 PHSO rec
94 IMB recs
2 Scottish FAIs
1692 DHR recs
12 PHSO decisions
48 LGO/SPSO decisions
11 CJINI reports
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(11)
155 — Press to promote public understanding
Recommendation: The press should be encouraged to enable a greater understanding by the public of the problems of child sexual abuse and of child protection work (18.38).
Unknown
3 — Increase public awareness of child sexual abuse
Recommendation: Steps should be taken to increase public awareness of the problem of child sexual abuse and of the difficulties inherent in the work of investigation of child abuse (15.17).
Unknown
FR-4 — Public Awareness Campaign
Recommendation: The Inquiry recommends that the UK government and the Welsh Government commission regular programmes of activity to increase public awareness about child sexual abuse and the action to take if child sexual abuse is happening or suspected in England and …
Gov response: We accept the importance of bringing child sexual abuse out of the shadows and creating more national awareness of the scale and nature of the issues and how to report concerns and cases of child …
Accepted in part
R95 — Blue light protocol for at-risk registers
Recommendation: HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in order to target community resources efficiently and prevent the person having to leave their home in the community.
No response yet
6 — Review and reduce cell lock-in periods
Recommendation: The Home Office, in consultation with the contractor responsible for operating each immigration removal centre, must review the current lock-in regime and determine whether the period of time during which detained people are locked in their cells could be reduced. …
Gov response: 6.3.1. A new staffing model has been developed to deliver a considerably healthier ratio of custodial staff per detained individual to nearly double what it was in 2017. The new model represents an increase in …
Accepted, fully or in part (not specified)
1 — Monitor Brook House contract performance robustly
Recommendation: The Home Office must actively and robustly monitor the performance of the Brook House contract, including satisfying itself that any self-reported information is accurate. This may include engagement with monitoring bodies and appropriate stakeholders. Penalties must be attached to inadequate …
Gov response: 6.1.1.The government is committed to addressing the key issues found in the report around the terms and monitoring of contracts, holding the most senior service provider managers to account as well as those delivering services …
Accepted
39 — Training to consider child's self-protection
Recommendation: In all training in matters of child abuse account should be taken of the opportunity which a child has to take steps for his or her own protection (16.8).
Unknown
6 — Active role for Area Child Protection Committees
Recommendation: Area Child Protection Committees should be encouraged to take active initiatives in suggesting courses of action, training, practical planning and other positive projects to secure that the whole needs of child protection are effectively and efficiently met in their area …
Unknown
COVID-M4.3 — Improve Vaccine Uptake Monitoring and Evaluation
Recommendation: Each of the four UK public health or health security agencies should work together to: maintain accurate, UK-wide insight into the state of vaccine uptake and hesitancy; and understand the measures proven to be effective in increasing uptake across the …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 4 report of 16 April 2026 when the Executive Office's publications list was checked on 25 September 2026.
Accepted
COVID-M4.2 — Formalise Community Vaccine Equity Networks
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive should maintain networks with local communities to produce targeted vaccination strategies and communications. To achieve this: The Scottish Government, Welsh Government and Northern Ireland Executive should establish local community …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 4 report of 16 April 2026 when the Executive Office's publications list was checked on 25 September 2026.
Accepted in part
AC-1a — Open Registration
Recommendation: The scheme be opened to registration to everyone who may be eligible.
Gov response: Today (Monday 21 July 2025) we have given our response to the Infected Blood Inquiry additional report published on 9 July. We accept all recommendations in the report for IBCA.
Accepted
Prevention of Future Deaths reports(92)— showing 50 strongest matches
Ann Margaret Spearing
Concerns: Organisations' criteria excluded the individual from care, leading to her being passed between agencies without effective intervention due to an identified lack of funding methods for such complex cases.
Response (Bristol Clinical Commissioning Group): • The Clinical Commissioning Group (CCG) is re-procuring specialist mental health and learning disability services, with an expanded range of services anticipated by October 2014. • A Primary Care Liaison … (AI summary)
Responded
Amna Umer Ahmed
Concerns: The coroner noted a potential low awareness of Sudden Arrhythmic Death (SAD) in general practice, alongside an apparent lack of, or awareness of, guidelines for GPs regarding urgent referrals for patients vulnerable to SAD.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated that its GP Curriculum, which forms the foundation for GP training, covers cardiovascular disease, including prevention, cardiac arrhythmias, and emergency care. • … (AI summary)
Overdue
Amanda Vickers
Concerns: Insufficient availability of beds at the county's sole mental health crisis home meant a patient died while awaiting admission. The report notes the need for a review of facility provision.
Response (Cumbria Clinical Commissioning Group): • The CCG is reviewing its previous mental health and wellbeing framework strategy. • The CCG plans to develop a new Mental Health Strategy for Cumbria, involving stakeholders and public … (AI summary)
Responded
Oliver Hiscutt
Concerns: The coroner noted that paediatric child health training is not mandatory for GPs, with less than 25% of trainees undertaking placements, potentially leading to insufficient skills in assessing and responding to sick children.
Overdue
Samarjit Singh
Concerns: There was no Specialist Community Perinatal Mental Health Service in Wirral, resulting in sub-optimal treatment. Additionally, the Liverpool City Region lacked a Mother and Baby in-patient Unit, leading to many distant referrals being declined.
Response (Wirral Clinical Commissioning Group): • An additional perinatal mental health midwife post was approved and filled, increasing the number of such midwives to two. • The new specification for IAPT services includes a requirement … (AI summary)
Response (Department of Health): • NHS England developed a specification for specialised perinatal services, including Mother and Baby Units. • The Department of Health copied the correspondence to the Chief Nursing Officer for England … (AI summary)
Overdue
Helena Farrell
Concerns: Concerns were raised regarding an inadequate CAMHS referral system and staffing levels, alongside an unrealistic workload for the school nurse service. The coroner also noted unverified qualifications and professional registration for the school counsellor.
Response (Cumbria NHS Foundation Trust): • The Child and Adolescent Mental Health Service (CAMHS) referral system was redesigned, establishing a 48-hour response target for urgent referrals. • Staffing levels across CAMHS increased from 45 to … (AI summary)
Response (Cumbria County Council): • The Council funded three additional posts within the School Nursing Service and carried out a full case audit. • The Council is working to amend multiagency safeguarding systems and … (AI summary)
Responded
Emmanuel Akinmuyiwa
Concerns: The coroner identified a lack of clear protocols in the West Midlands for managing sickle cell disease patients, noting that hospital staff had insufficient knowledge of crisis signs and treatment. This was compounded by a lack of funding to implement a regional 'hub and spoke' approach with consistent guidelines.
Overdue
Sian Armstrong
Concerns: The coroner noted a delay in a child receiving required CBT and sought assurances that this therapy would be available to children in a timely manner from North Bristol NHS Trust.
Overdue
Aleysha McLoughlin
Concerns: The coroner identifies insufficient professional training to recognise self-harm in young people, a lack of systems encouraging young people to report peers, and gaps in multi-agency discussions, particularly for those resisting engagement.
Response (Department of Health): • The Department of Health noted that the 'Future in Mind' report (March 2015) established a national ambition to transform the design of services for children and young people with … (AI summary)
Responded
Baby Olsberg
Concerns: The coroner noted the NHS does not routinely offer antenatal screening for Group B Streptococcus (GBS) or prophylactic intrapartum antibiotics to all GBS-positive pregnant women, raising concerns about potential risks to babies.
Response (Royal College of Obstetricians and Gynaecologists): • The Royal College of Obstetricians and Gynaecologists (RCOG) stated that routine antenatal screening for Group B Streptococcus (GBS) is not recommended, aligning with National Screening Committee guidance. • The … (AI summary)
Response (N.I.C.E): • The organisation's clinical guideline on antenatal care (CG62, 2008) does not recommend routine screening for Group B Streptococcus (GBS). • The organisation reviewed the evidence in 2014 and determined … (AI summary)
Response (Department of Health): • The UK National Screening Committee (UK NSC) will review the evidence for antenatal screening for GBS in 2015/16, with a commissioned modelling exercise reporting in late autumn 2015. • … (AI summary)
Responded
Emma Carpenter
Concerns: The coroner noted short-term funding for the specialist Eating Disorder Service and a national lack of inpatient beds for mentally ill children. Gaps were also identified in school nurses' attendance at Multi-Disciplinary Meetings due to funding, impacting communication with education staff.
Response (Department of Health): • The Department of Health provided £7 million to NHS England in 2014/15, which supported the commissioning of over 60 new CAMHS Tier 4 beds. • NHS England distributed £30 … (AI summary)
Response (NHS England): • NHS England is investing £30 million per year for Clinical Commissioning Groups to develop and deliver community eating disorder services. • Access and time standards for evidence-based eating disorder … (AI summary)
Response (Doncaster and Bassettlaw Hospitals NHS Trust): • The Trust formally communicated with Nottinghamshire Healthcare Foundation Trust to understand how to support patients from the Bassetlaw area. • The Trust offered a formal service level agreement and … (AI summary)
Responded
Isabella Drew
Concerns: The coroner identified a need for more explicit guidance on how local healthcare providers advise pregnant women about whooping cough vaccination, including audit and follow-up. Additionally, national guidance is needed for effective communication among antenatal care providers.
Response (NHS England): • Public Health England (PHE) introduced collection of pertussis vaccination uptake figures by ethnicity and extended enhanced surveillance to include maternal immunisation history and ethnicity. • PHE engaged with professional … (AI summary)
Responded
Curt Falk
Concerns: The coroner noted that current vaccination policy does not include males against a viral infection, which poses a risk of future deaths in men from the consequences of this infection.
Response (JCVI): • The Joint Committee on Vaccination and Immunisation (JCVI) established an HPV sub-committee in October 2013 to consider extending the HPV vaccination programme to adolescent boys and men who have … (AI summary)
Overdue
William Higgleton
Concerns: The coroner noted a lack of service provision for psychotherapy care for individuals with anti-social personality disorder. This gap in provision was identified as posing a risk of future deaths.
Response (William Higgleton): • The North East London NHS Foundation Trust (NELFT) and Clinical Commissioning Groups (CCGs) agreed to review care pathways for patients with anti-social personality disorder. • A communication plan will … (AI summary)
Overdue
Simon Klineberg
Concerns: Availability of psychiatric beds, resource allocation for the home treatment team's support threshold, and the management of psychological therapy waiting lists, particularly for high-risk patients, were noted as areas of concern.
Overdue
Christina O’Brien
Concerns: The coroner identified limited non-hospital respite care options for mentally ill people in the community, noting the withdrawal of the beneficial Dove House facility without alternative provision. It was recorded that if such an option had been available, it might have prevented the death and could prevent future self-inflicted deaths.
Overdue
Oliver Ford
Concerns: The coroner raised concerns regarding the telephone triage process, noting a need to include a risk assessment within it and ensure all risk assessments are documented. There were also concerns about the weekend cover for the PCLS service to prevent delays in patient follow-up.
Response (Avon and Wiltshire NHS Trust): • The telephone triage process now incorporates an Access Trigger Tool to conduct in-depth risk assessments. • Clinicians are required to document a full rationale for decision-making on RIO following … (AI summary)
Responded
Thomas Green
Concerns: The coroner noted an unactioned psychiatric referral during an inpatient stay and a subsequent unsuitable referral to Healthy Minds for complex PTSD due to insufficient detail. A commissioning gap for complex PTSD services was also identified.
Response (Tameside and Glossop CCG NHS Trust): • The CCG met with Pennine Care NHS Foundation Trust staff to identify actions for service improvements. • The CCG will clarify the Individual Funding Request process and brief Pennine … (AI summary)
Overdue
Vadims Aleksejevs
Concerns: The coroner raised concerns regarding the clarity and provision of outreach services by adult social care and addiction services for vulnerable individuals on a campsite. Questions were noted about available housing options and statutory duties to house these individuals.
Response (Vadims ALEKSEJEVS): • Northamptonshire County Council's Adult Social Care team commissions outreach services for homeless individuals through two drug and alcohol support services. • The Council clarified its statutory duty to house … (AI summary)
Overdue
Annabel Lewis
Concerns: The coroner noted deficiencies in handling a referral, including a lack of recorded risk level, next of kin details, and follow-up arrangements after an appointment was declined. There was also no proactive engagement with the young person's parents to facilitate access to services.
Overdue
Isabel Gentry
Concerns: The coroner noted evidence suggesting Isabel's death from meningitis B could have been prevented by vaccination, raising concerns about the ongoing risk to teenagers as the vaccination program does not include this age group.
Overdue
John Haughey
Concerns: The coroner raises concerns that information about the potential hazard of confused patients consuming alcohol-based hand gels has not been widely disseminated across the NHS and other sectors. Organisations should be aware of this risk and conduct appropriate formal risk assessments.
Overdue
Jamie Pashley
Concerns: The coroner raised concerns about post-detoxification care, asking whether individuals should receive fixed appointments, telephone contact between discharge and first review, and increased availability of an alcohol liaison nurse.
Response (Kings College Hospital NHS Trust): • The Trust is participating in a trial of a more assertive follow-up approach for alcohol dependency patients prior to discharge. • The Trust is considering a business case to … (AI summary)
Overdue
Tomas Kelly
Concerns: Concerns were raised regarding the inconsistent provision of information to parents of children with Down Syndrome about their increased infection risks, and the need to consider routine chickenpox vaccination for this group.
Response (Joint Committee on Vacccination and Immunisation): • The Joint Committee on Vaccination and Immunisation stated it would give consideration to the suggestion regarding Down’s syndrome during its ongoing review of varicella vaccination advice. (AI summary)
Responded
Evelyn Fisher
Concerns: The coroner noted the driver likely had undiagnosed dementia before the incident. Concerns were raised that the current licence renewal scheme for over-70s relies on self-reporting and lacks mandatory objective testing for fitness to drive.
Overdue
Charlie Craig
Concerns: British Cycling does not undertake health assessments or medical screening for young riders on its World Class Programme. A cardiologist indicated such screening can identify cardiac abnormalities in asymptomatic young people.
Response (British Cycling): • British Cycling stated that new cardiac screening guidelines are being developed for all athletes on the World Class Programme, including those at apprentice level. • The recommendations for these … (AI summary)
Responded
Raymond Davidson
Concerns: The coroner noted ongoing operational shortages and insufficient ambulance resources within NEAS led to significant delays in urgent case responses. Concerns were also raised about indirect patient contact potentially impacting the initial clinical review.
Overdue
Bernard Gerrard
Concerns: The coroner noted significant delays in ambulance response times, including a 10-hour wait for a Category 3 call. EMAS indicated that insufficient funding and demand are causing unacceptable response times.
Response (East Midlands Ambulance Service NHS Trust): • An Independent Strategic Demand and Capacity Review was undertaken and concluded, identifying a substantial resource gap. • An Urgent Care Transport Service (UCTS) was established and commenced operations on … (AI summary)
Overdue
William Abrahams
Concerns: The coroner raises concerns that the Abdominal Aortic Aneurysm (AAA) screening programme's age criteria excluded Mr Abrahams, and notes that the asymptomatic nature of AAAs makes the benefits of opting in unclear to patients.
Response (NHS England): • The response described past communication and engagement plans, including informing GP practices and holding public events to promote awareness and self-referral for eligible men. • NHS England London Region … (AI summary)
Responded
Karen Edgar
Concerns: The coroner noted underfunding and long delays in mental health services for children and young people in Cumbria. This raises concerns about young people entering adulthood with unresolved mental health issues, leading to significant human and financial costs.
Response (Department of Health Social Care): • The Government has made an additional £1.4 billion available to improve children and young people's mental health services. • NHS England has developed a service transformation programme and invested … (AI summary)
Overdue
Alfie Scambler-Holt
Concerns: The coroner noted the absence of a national Paediatric Early Warning Score (PEWS) system, which results in different systems across trusts and creates challenges for staff when children move between institutions.
Overdue
Enric Elliott
Concerns: The coroner identified that vulnerable young mothers who book maternity care late (after 28 weeks) are often excluded from the Family Nurse Partnership, thereby missing crucial support despite late booking being a risk factor for their child.
Response (Whittington Health NHS Trust): • The Trust changed its referral criteria to accept mothers up to 25 years old into the local programme. • The Trust will consider, on a case-by-case basis, accepting referrals … (AI summary)
Responded
David Sargeant
Concerns: The coroner noted the lack of commissioned services for adult ADHD assessment, diagnosis, and treatment within Cornwall, along with practical difficulties in managing out-of-county referrals for ongoing medication oversight.
Response (Kernow Clinical Commissioning Group): • NHS Kernow CCG committed recurrent investment to develop and deliver an adult ADHD assessment, diagnosis, and treatment pathway. • A Shared Care Agreement and Guideline for the treatment of … (AI summary)
Responded
Neil Swaisland
Concerns: The coroner noted the withdrawal of funding for MIND's counselling services by the Council and CCG, raising concerns that this decision could lead to further deaths from suicide among vulnerable individuals.
Response (Milton Keynes Council): • Milton Keynes Council and Milton Keynes Clinical Commissioning Group confirmed a continuation of funding for MIND's counselling services until April 2019. • The Council stated it would re-focus its … (AI summary)
Response (Milton Keynes Clinical Commissioning Group): • Milton Keynes Clinical Commissioning Group (MKCCG) maintained statutory grant funding for MIND's counselling services until March 2019. • MKCCG invested in Improving Access to Psychological Therapies (IAPT) service provision, … (AI summary)
Responded
Edward Farmer
Concerns: A national campaign is needed to address the inherent risks of rapid alcohol consumption, how to identify at-risk persons, the importance of timely medical intervention, and risks associated with initiation events.
Response (Department for Education): • The Department for Education stated that comprehensive guidance, 'Initiations at UK Universities,' was published by Universities UK and Newcastle University on 23 September. • The guidance aims to raise … (AI summary)
Response (Department of Health and Social Care2): • Universities UK and Newcastle University published guidance on 23 September 2019 to raise awareness of the dangers of initiations and excessive alcohol consumption among students. • Public Health England … (AI summary)
Response (Newcastle University): • Newcastle University and Newcastle University Students' Union established a Student Initiations Group to address the coroner's concerns. • The Student Initiations Group created a workstream focused on raising awareness … (AI summary)
Response (Secretary of State): • The department will work with colleagues in the health and education sectors. • The department will design measures to raise awareness of alcohol risks and encourage sensible decisions. • … (AI summary)
Response (NUS): • The NUS detailed its existing initiatives, including campaigns, accreditation schemes, and behaviour change programmes, which address responsible alcohol consumption and high-risk drinking among students. • The NUS stated a … (AI summary)
Responded
Douglas Minns
Concerns: The coroner noted the withdrawal of a falls service, which previously assisted individuals who had fallen at home. This withdrawal risks patients' lives and contributes to long waits for ambulance service response.
Response (Milton Keynes Clinical Commissioning Group): • Milton Keynes Clinical Commissioning Group stated that the original falls service was superseded by a 24/7 Home 1st Rapids service. • The Home 1st Rapids service provides experienced nurse … (AI summary)
Responded
Jack May
Concerns: The coroner noted inadequate provision of counselling and wellbeing services at Cardiff University, citing long waiting times and a reapplication process after four appointments. There are also concerns about inconsistent pastoral support from Personal Tutors, with limited training and varying levels of student contact.
Response (Cardiff University): • The university is evaluating its approach to managing student mental health crises, reviewing related policies, and has allocated £150,000 for new posts to risk assess and triage these situations. … (AI summary)
Responded
Noah Lomax
Concerns: Concerns were raised about the adequacy of the CAMHS GP referral form, as insufficient detail provided by a GP led to a referral being declined and delayed care. The coroner suggests the Trust reconsiders improving the form to reduce the risk of insufficient information.
Response (Sheffields Childrens NHS Trust): • Referral guidelines were updated with input from a General Practitioner and are now in use. • The CAMHS team commenced a review of the referral form, and a draft … (AI summary)
Responded
Reece Lapina-Amarelle
Concerns: The coroner identified a lack of resources, treatment systems, and information sharing for individuals with serious mental illness and co-occurring alcohol or drug misuse. The Mental Health Act was also noted as outdated in addressing these complex needs and prioritising patient safety.
Response (Department of Health and Social Care): • The Department asked officials to make the report and circumstances known to the Care Quality Commission. • The Department noted that Public Health England developed guidance and the National … (AI summary)
Response (NHS England): • NHS England stated that the NHS Long Term Plan details new and integrated models of primary and community health services to transform mental health care for adults with serious … (AI summary)
Responded
Mohan Acharya
Concerns: The coroner noted that emergency department crowding is associated with increased mortality among admitted patients, with approximately 500 deaths per year attributed to overcrowded emergency departments.
Response (the Department of Health and Social Care): • The Department stated that part of the £1.6 billion additional funding received by the NHS in 2018/19 had been used to deliver improvements. • The Government provided £145 million … (AI summary)
Responded
Rifky Grossberger
Concerns: The coroner noted parents were unaware of the danger of metal blind cords and suggested better dissemination of safety information to new parents through healthcare professionals, postnatal leaflets, and the NHS website.
Response (NHS England): • NHS England stated that advice on ligature risks, including blind safety, is available on the NHS Choices website. • Public Health England advised that the national Healthy Child Programme … (AI summary)
Response (Royal College of Nursing): • The Royal College of Nursing reviewed and strengthened its guidance on strangulation and suffocation risks on its clinical webpages for relevant nursing professionals. • The Royal College of Nursing … (AI summary)
Responded
Isaac Newton
Concerns: The coroner identified that some parents do not appreciate or follow guidance on safe sleeping practices for young infants, particularly regarding co-sleeping and awareness of associated risks, despite efforts to provide advice.
Response (Dept of Health and Social Care): • Public Health England (PHE), in collaboration with the Lullaby Trust, released two short films providing advice on safe sleeping. • The Department of Health and Social Care (DHSC) committed … (AI summary)
Responded
Reggie-Jay Payne
Concerns: The coroner noted Group B Strep (GBS) was not discussed with the mother during pregnancy, preventing her from being aware of the infection's dangers. The report suggests the trust consider introducing a routine GBS screening program for all pregnant mothers.
Overdue
Carolyne Senior
Concerns: The coroner noted concerns that hospital staff did not adequately consider mental health needs in falls risk assessments, and that specialist mental health provision to support staff in caring for such patients might be insufficient.
Response (Barnsley Hospital NHS Foundation Trust): • The Trust has incorporated specific questions regarding diagnosed mental health conditions and their impact on falls risk into the Root Cause Analysis document. • The falls risk assessment process … (AI summary)
Responded
Michelle Turner
Concerns: The coroner raised concerns about the potential loss of funding for peer support workers in March 2021, highlighting their invaluable support and unique lived experience in assisting individuals with mental health and substance misuse issues.
Response (Blackpool CCG): • The CCG agreed to extend the sub-contract arrangement for peer support workers until March 2022. • An Integrated Care System transformation model, which includes peer support workers, is being … (AI summary)
Responded
Violet Jackman
Concerns: The coroner noted a lack of clear assurance that both parents understood safe sleeping advice, as health visitors did not ask for descriptions of arrangements. Concerns also included reduced health visitor services due to COVID-19 redeployment.
Response (Department of Health and Social Care): • The Department committed to implementing three national recommendations from the Child Safeguarding Practice Review Panel report on sudden unexpected death in infancy. • Public Health England will consider how … (AI summary)
Responded
Cyril Cheetham
Concerns: The coroner raised concerns that the Alternative to Transfer (ATT) service may delay admissions for elderly patients due to an additional layer of telephone triage. There is no adequate audit of its net benefit or research into deaths from delayed admissions where the ATT service was used.
Response (Dept of Health and Social Care): • Mastercall is reviewing all calls to the Alternative to Transfer service. • Mastercall has committed to conducting a full audit of the Alternative to Transfer service. • Stockport CCG … (AI summary)
Response (Stockport Clinical Commissioning Group): • Mastercall instigated a change to its Clinical Guardian system to review all Alternative to Transfer (ATT) calls. • Mastercall is undertaking a full audit of the ATT service, with … (AI summary)
Responded
Averil Hart
Concerns: The coroner identified inadequate training of medical professionals regarding eating disorders, specifically Anorexia Nervosa, including inconsistent implementation of treatment guidelines. There is also a continuing shortage of eating disorder specialists across the country.
Response (NHS England): • NHS England has developed a national programme, supported by significant investment, to expand and improve adult eating disorder services. • NHS England is working with Health Education England to … (AI summary)
Response (GMC): • The GMC updated its 'Outcomes for graduates' in 2018 and is introducing a Medical Licensing Assessment from 2024/25, which includes eating disorders in its content map. • The GMC … (AI summary)
Response (Department of Health Social Care): • The Department of Health and Social Care is working with a delivery group, including NHS England and Improvement and Health Education England, to address recommendations from a Parliamentary and … (AI summary)
Response (NHS England): • Health Education England (HEE) introduced commissioned learning resources for medical students and Foundation doctors to improve mental health awareness, including eating disorders. • HEE commissioned education programmes to upskill … (AI summary)
Responded
Anastasia Uglow
Concerns: The coroner raises concerns about the general lack of sepsis awareness in schools, noting the tragic consequences if the condition is left untreated. The report aims to promote greater sepsis awareness among school staff nationally.
Response (Department for Education): • The Department noted that the Outdoor Education Advisers' Panel (OEAP) is working with the school and the UK Sepsis Trust to update national guidance on sepsis awareness. • The … (AI summary)
Responded
Steven Regoli
Concerns: The report raises concerns about the lack of systems and appropriate pathways for individuals with severe mental health conditions who struggle to engage with services, leading to insufficient support and reliance on family care.
Overdue
Select committee recommendations(417)— showing 50 strongest matches
#29 —
Recommendation: The Government should take steps to ensure that the implications of the technological shifts required for net zero and adapting to climate change for noise and light pollution are understood and addressed early on.
Response attribution not verified
#23 —
Recommendation: Mapping and modelling tools should be used to identify the most cost-effective interventions to reduce the disease burden of noise pollution, including determining where retrofits make sense. Information on how to reduce noise pollution must be made available at the …
Response attribution not verified
#22 —
Recommendation: The hierarchy of interventions for noise pollution should be: reduce, restrict, remodel. It is generally more effective to reduce noise at source, through planning and engineering, than it is to restrict transmission using sound barriers or to remodel the receiver’s …
Response attribution not verified
#20 —
Recommendation: The Government should use its mapping to identify key cost-effective interventions. The noise mapping and modelling should be made public. The Government should use this to update the burden of disease calculations used for noise pollution, including any new scientific …
Response attribution not verified
#19 —
Recommendation: The Committee welcomes DEFRA’s noise pollution mapping and modelling exercise, which provides an opportunity for a renewed focus on noise pollution. However, mapping is only the first step: interventions to reduce the noise burden must follow.
Response attribution not verified
#8 —
Recommendation: The Government should commission research to establish how light intensity, wavelength, duration, time of exposure, light history and age affect the circadian system. This should move beyond laboratory-based studies and investigate more realistic light exposure patterns for humans. Such knowledge …
Response attribution not verified
#21 —
Recommendation: It is worrying that some institutions would be unwilling to engage with the OfS in the early stages of falling into financial difficulty for fear of a punitive regulatory response, especially given the OfS’ risk-based approach to engagement. This hampers …
Response attribution not verified
#93 —
Recommendation: Regulatory enforcement is necessarily reactive, but this lack of monitoring forces policy making and problem solving also to be reactive. A lack of forward planning and programmes means issues cannot be addressed before they reach this legal backstop. Crawley Borough …
Response attribution not verified
#193 —
Recommendation: Partnerships with a range of local organisations, outside formal commissioning processes for rehabilitative services, are also key to securing meaningful unpaid work placements that foster public support for community sentences.
Response attribution not verified
#192 —
Recommendation: Commissioned rehabilitative services are a key component of community sentences. The delivery partners of the Probation Service provide valuable services. The most recent commissioning wave, while imperfect, is considered by all parties as a step in the right direction.
Response attribution not verified
#128 —
Recommendation: Initiatives for mentoring should be scaled up. Mentors can be people who have previously been on probation themselves or volunteers from the community. The Government should launch a national campaign to recruit mentors from the community. Charitable organisations should be …
Response attribution not verified
#127 —
Recommendation: The Government should create incentives for low-level, âprolificâ offenders to engage with rehabilitation. It could find inspiration in the principles underpinning âIntegratedâ Community Service Order from Ireland, also addressing upfront the operational challenges identified in Ireland. Offenders should be given …
Response attribution not verified
#126 —
Recommendation: An interesting approach is being tested in Ireland. While their efficacy remains to be confirmed, the mechanisms of the âIntegratedâ Community Service Orders are intended to create incentives for people on probation to engage with rehabilitation and in a range …
Response attribution not verified
#124 —
Recommendation: The better approach is to incentivise offenders. Deferred sentencing can be used to encourage offenders to engage with probation, rewarding positive behaviour in the deferred sentence. Various initiatives have been or are being piloted to create incentives for low-level, repeat …
Response attribution not verified
#123 —
Recommendation: The rehabilitative needs of low-level, repeat offenders are not being met. Increasing the tariff of their punishment, be it in an individual case or through a revision of sentencing guidelines, is not the solutionâit would set people up to fail, …
Response attribution not verified
#122 —
Recommendation: Some witnesses, however, expressed reservations about the current use of out-of-court disposals (where the police deal with a low-level, often first-time offender without prosecution) in the UK. Tom Franklin referred to âan unregulated increase over the past few yearsâ, and …
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
#120 —
Recommendation: We also heard about deferred sentences. Dr Graham told us that Scottish sheriff courts can decide to âdefer sentence for approximately six monthsâ during which the offender is supported and supervised, and to âsentence at the end of thatâ, giving …
Response attribution not verified
#119 —
Recommendation: When someone is sentenced to a community order, it is âvitalâ that they are assigned a peer mentor, we heard from Pavan Dhaliwal. She explained that someone who has previously been on probation can help an offender make the most …
Response attribution not verified
#118 —
Recommendation: We heard that mentors could encourage offenders engage with rehabilitation, whether they have been on probation themselves or are lay members of the public. Damian Hinds MP told us that âthere definitely is a roleâ for mentors. 230 He defined …
Response attribution not verified
#117 —
Recommendation: Inspiration could be found in that model. Chief Probation Officer Kim Thornden-Edwards told us that she has ânot looked at the Ireland modelâ, but said that âthe idea of being able to reduce the sentence by up to one-third is …
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
#114 —
Recommendation: Integrated CSOs are rewarding. Dr Guilfoyle pointed out that âit also means that the Probation Service is encouraging the person to participate, and rewarding them if they do soâ whereas, âby comparison, the approach here in England and Wales is …
Response attribution not verified
#113 —
Recommendation: âThe concept of an integrated Community Service Order aligns better with principles of desistanceâ, Dr Guilfoyle argued. 219 He explained that âgiving a person the option to opt in and the ability to choose the type of personal development activity …
Response attribution not verified
#112 —
Recommendation: Dr Eoin Guilfoyle, Lecturer in Criminal Law and Criminal Justice, Brunel University London, drew our attention to the âintegrated Community Service Orderâ (CSO) in Ireland, which creates incentives for people on probation to engage with rehabilitative activities. He explained the …
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
#109 —
Recommendation: Witnesses were particularly concerned about âputting people into situations where they have multiple appointments that they need to keep which they fail to do soâ: it can result in them being found in breach of their sentence and recalled before …
Response attribution not verified
#108 —
Recommendation: On the other hand, witnesses warned against the temptation of âup-tariffing people into more supervisionâ. 201 While he acknowledged that âa legal decision has already been made that repetition aggravates an offenceâ, Gavin Dingwall told us that this should not …
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
#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
#98 —
Recommendation: Rebecca Robson, for instance, told us about Womenâs Community Matters in Cumbria and the wide range of services the organisation offers: âWe run an eight-week group course called Womenâs First, which each week responds to a different pathway to reoffending, …
Response attribution not verified
#97 —
Recommendation: We heard about the best practices arising from the work of womenâs centres. Women in Prison told us that âapproaches based around prevention, early intervention and community-based support, are evidenced to be effective at reducing reoffending and support women in …
Response attribution not verified
#91 —
Recommendation: Current efforts to improve treatment services and increase their availability should be sustained. Further investment in Community Sentence Treatment Requirements is required and should be a priority. CSTRs are key to reducing reoffending, putting offenders on a path away from …
Response attribution not verified
#90 —
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
#89 —
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
#85 —
Recommendation: Chris Jennings also told us he was determined to see an increase in the availability of treatment services: âThe Community Sentence Treatment Requirements are the area where I want to see most progress. If we cannot address peopleâs mental health …
Response attribution not verified
#72 —
Recommendation: The Government acknowledges that helping people on probation face their addictions or mental health issues helps reduce crime. Damian Hinds MP told us that: âDrug addiction is the fuel, the driver, behind acquisitive crime and all manner of other crimes …
Response attribution not verified
#68 —
Recommendation: The Government should invest in the services that underpin community orders to satisfy sentencers of their efficiency and availability. The emphasis should be put on intensive treatment, the effectiveness of which is established.
Response attribution not verified
#67 —
Recommendation: Community orders should be used more frequently. While it is the responsibility of the independent Judiciary to decide what sentence is appropriate in each case brought before Courts, it is the role of the Government to make sentences available to …
Response attribution not verified
#57 —
Recommendation: We heard that the decline in the use of community sentences may also be related to sentencers having, at some point, lost trust in them or how they used to be enforced. Lord Justice William Davis, Chair of the Sentencing …
Response attribution not verified
#41 —
Recommendation: Our impression throughout our inquiry was that Government and senior management seems to have lost sight of low-level offenders and to be preoccupied with the size of the prison population and post-release supervision, perhaps because of recent institutional reorganisations. Supervising …
Gov response: 150. We are committed to delivering our priorities across the criminal justice system. The prison population in England & Wales is greater than it has ever been, and so it is right that we must …
Position Not Stated
#30 —
Recommendation: Commissioned rehabilitative services are a key component of community sentences. The delivery partners of the Probation Service provide valuable services. The most recent commissioning wave, while imperfect, is considered by all parties as a step in the right direction.
Response attribution not verified
#21 —
Recommendation: An interesting approach is being tested in Ireland. While their efficacy remains to be confirmed, the mechanisms of the âIntegrated â Community Service Orders are intended to create incentives for people on probation to engage with rehabilitation and in a …
Response attribution not verified
#19 —
Recommendation: The better approach is to incentivise offenders. Deferred sentencing can be used to encourage offenders to engage with probation, rewarding positive behaviour in the deferred sentence. Various initiatives have been or are being piloted to create incentives for low-level, repeat …
Response attribution not verified
#14 —
Recommendation: Current efforts to improve treatment services and increase their availability should be sustained. Further investment in Community Sentence Treatment Requirements is required and should be a priority. CSTRs are key to reducing reoffending, putting offenders on a path away from …
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
HSSIB safety recommendations(9)
Potential under-recognised risk of harm from the use of propranolol
The Practice has reorganised the main display board in the waiting area to focus on mental health support. 4.2 Analysis and findings from the wider investigation Propranolol use
Safety Action
Management of chronic asthma in children aged 16 years and under
It may be beneficial for a health intervention to be delivered to enhance the general public’s knowledge and understanding of asthma, emphasising the potential seriousness of the condition. This could be linked to the modernisation of the Healthy Child Programme, …
Safety Observation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that Public Health England develops resources for young people and their parents/carers to raise awareness and enable them to self-manage asthma more effectively.
Safety Recommendation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS England and NHS Improvement, as a commissioning body, supports local systems to implement evidence-based interventions, such as standardised information and wheeze management plans, for the parents/carers of pre-school children. This will be undertaken in conjunction with …
Safety Recommendation
Investigation report: Mental health inpatient settings - out of area placements
Healthcare services can improve patient safety by conducting assessments for neurodevelopmental conditions such as autism and attention deficit hyperactivity disorder, where it is safe and clinically indicated, at the earliest opportunity when a person is in contact with community and …
Safety Observation
Investigation report: Mental health inpatient settings - out of area placements
Mental health services can improve patient safety by reviewing their community mental health services to see if they meet the needs of their population with the aim of keeping as many people as possible out of inpatient services and thus …
Safety Observation
Digital tools for online consultation in general practice
National healthcare organisations can improve patient safety by considering how long-term condition management and proactive health promotion can be accomplished alongside the online consultation model of general practice, which may limit opportunities to provide holistic care to patients.
Safety Observation
Insulin: supporting safe self-administration for patients in the community with a mental health problem
HSSIB recommends that the National Institute for Health and Care Research, in collaboration with relevant research and policy stakeholders: 1) maps the knowledge gaps surrounding type 1 diabetes and disordered eating (including those identified in this investigation); and 2) assesses …
Safety Recommendation
Never events: analysis of HSIB's national investigations
It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available.
Safety Recommendation
NCEPOD recommendations(10)
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
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
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
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
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
CQC inspection actions(34)
Queen's Medical Centre
The trust should ensure carbon monoxide testing is offered to all pregnant women at antenatal booking appointment and at 36 weeks.
Should Do
Queen's Medical Centre
The trust should ensure carbon monoxide testing is offered to all pregnant women at antenatal booking appointment and at 36 weeks.
Should Do
Princes Medical Centre
Continue to monitor and take actions to improve the uptake for childhood immunisations and cervical cancer screening for women at the practice.
Should Do
Nottingham City Hospital
The trust should ensure carbon monoxide testing is offered to all pregnant women at antenatal booking appointment and at 36 weeks.
Should Do
Nottingham City Hospital
The trust should ensure carbon monoxide testing is offered to all pregnant women at antenatal booking appointment and at 36 weeks.
Should Do
Glemsford Surgery
Continue to review and improve the opportunities for patients to access health screening checks.
Should Do
Clatterbridge Hospital
The services should consider ways to improve support and advice given to children and young people to lead healthier lives.
Should Do
Clatterbridge Hospital
The services should consider the availability of information leaflets for health promotion.
Should Do
St Benedict's Hospice
The service should consider displaying health promotion posters or information on the walls of the waiting area.
Should Do
The Sidings Medical Practice
Continue their work to improve uptake of childhood immunisations and cervical screening.
Should Do
Old Hall Surgery
Continuetomonitorandimprovetheuptakeofcervicalscreeningandchildhoodimmunisations.
Should Do
Moorcroft Medical Centre
Continue to improve the uptake of childhood immunisations.
Should Do
Moorcroft Medical Centre
Continue to improve cervical and cancer screening uptake.
Should Do
Milton Keynes Hospital
The trust should continue to address the high smoking rates of pregnant women at booking and post delivery.
Should Do
Heath Street Health Centre
Continuetoincreasetheuptakeforcervical,breastandbowelcancerscreening.
Should Do
Heath Street Health Centre
Continuetoincreasetheuptakeofchildhoodimmunisations.
Should Do
Durham Diagnostics and Treatment Centre
The service should consider displaying health promotion posters or information on the walls of the waiting area.
Should Do
Queens Hospital
Ensure staff have access to an evidence-based standardised risk assessment and prioritisation tool for maternity triage.
Must Do
Family Nurse Partnership & Health Visiting
The service should ensure that they continue work to improve performance in completing checks for the mandated milestones outlined in the Healthy Child Programme.
Should Do
Charlton House Medical Centre
Arrangements for monitoring and review of patients with long-term conditions continued to place patients at risk of harm.
Must Do
Doncaster Royal Infirmary
The trust must assess, monitor, and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity.
Must Do
Moorcroft Medical Centre
Develop a strategy for non-compliant patient attendance when required for medicines and/or long-term condition monitoring.
Should Do
Waterbeach Surgery
Continuetomonitorandimproveuptakeforcervicalscreeningprogramme.
Should Do
Linden Road Surgery
Continue to monitor, and take actions to improve, attendance for cervical screening.
Should Do
Crown Street Surgery
Improve the uptake of cervical cancer screening.
Should Do
Camphill Health Centre
Continuetotakemeasurestoimprovetheuptakeofchildhoodimmunisationsandcervicalscreening.
Should Do
Bousfield Surgery
Take action to improve cervical screening and childhood immunisation uptake.
Should Do
Melville House
The provider must ensure people are supported to live healthy lives and access healthcare support promptly.
Must Do
B&H Care Ltd
The provider must ensure effective systems are in place to support people to maintain their health and wellbeing, including effectively identifying, monitoring, and managing people's health needs, and seeking and acting upon advice from health professionals.
Must Do
Crown Street Surgery
Improve the uptake of cervical cancer screening.
Should Do
Bousfield Surgery
Continuetoworktoimprovetheuptakeofcancerscreening.
Should Do
Gillmoss Medical Centre
Continuetoworktoimprovetheuptakeofcervicalcancerscreeningandimmunisation.
Should Do
The Highwood Surgery
Continueto improve the uptake of cervical screening.
Should Do
Dr Jude's Practice - Riverside & Picton
Continue to take steps to improve the childhood immunisations and cervical screening rates for the practice.
Should Do
HMICFRS recommendations(18)
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: Prevention activity doesn't always align with risks identified in the IRMP. Home fire safety checks aren't being done in a timely manner and there is a large backlog of high-risk cases. Recommendation: The service should ensure it …
Recommendation
FRS 2021-22 CoC Recommendations: Norfolk Fire and Rescue Service
Cause of concern: The service hasn’t made prevention activity a high enough priority and it isn’t adequately identifying those most at risk from fire. Recommendation: By 28 February 2022, the service should put in place plans that are designed to …
Recommendation
FRS unknown CoC Recommendations: Hertfordshire Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service. The service should implement a robust and consistent method of identifying risk and vulnerability. It should detail how it will prioritise home fire safety checks to those …
Recommendation
FRS 2021-22 CoC Recommendations: Hereford and Worcester Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service and it is not adequately identifying those most at risk from fire. Recommendation: By 31 August 2021, the service should have plans in place for the …
Recommendation
FRS 2023-25 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The executive board recognises it needs to do more in prevention. But not enough progress has been made since our last inspection to make prevention a sufficiently high priority for the service. The service should implement a …
Recommendation
FRS 2021-22 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service, and it is not adequately identifying those most at risk from fire. Recommendation: By 30 September 2021, the service should have plans in place for:- the …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service, and there is no prevention strategy, which should drive its day-to-day activities. The service doesn’t adequately prioritise home fire safety visits (HFSVs) on the basis of risk. …
Recommendation
FRS 2023-25 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest-risk premises to inform its risk-based inspection programme. Recommendation: Within 28 days, the service should review its action plan, detailing how it will develop a …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should review its systems and processes for dealing with …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to develop prevention activity that prioritises those most at risk of fire. Recommendation: By 31 August 2021, the service should develop a clear prevention strategy that prioritises the …
Recommendation
FRS 2023-25 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The executive board recognises it needs to do more in prevention. But not enough progress has been made since our last inspection to make prevention a sufficiently high priority for the service. The service should implement a …
Recommendation
FRS 2023-25 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to address its areas for improvement and provide clear direction to make sure that its teams can prioritise work according to risk. Recommendation: Within 28 days, the service …
Recommendation
FRS 2021-22 CoC Recommendations: Buckinghamshire Fire and Rescue Service
Cause of concern: Prevention activity is not a sufficiently high priority for the service, and it is not adequately identifying those most at risk from fire. Recommendation: By 30 September 2021, the service should have plans in place for:- the …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service, and there is no prevention strategy, which should drive its day-to-day activities. The service doesn’t adequately prioritise home fire safety visits (HFSVs) on the basis of risk. …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service, and there is no prevention strategy, which should drive its day-to-day activities. The service doesn’t adequately prioritise home fire safety visits (HFSVs) on the basis of risk. …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service, and there is no prevention strategy, which should drive its day-to-day activities. The service doesn’t adequately prioritise home fire safety visits (HFSVs) on the basis of risk. …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service, and there is no prevention strategy, which should drive its day-to-day activities. The service doesn’t adequately prioritise home fire safety visits (HFSVs) on the basis of risk. …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: Prevention activity isn’t a sufficiently high priority for the service, and there is no prevention strategy, which should drive its day-to-day activities. The service doesn’t adequately prioritise home fire safety visits (HFSVs) on the basis of risk. …
Recommendation
NAO audit recommendations(4)
NHS Financial Management and Sustainability
DHSC, NHSE and ICSs need to intensify their efforts to manage current and future demand for healthcare by preventing more serious ill health. This should include: ? work to improve understanding of what ICBs and providers have had success doing …
Partially accepted
Support for children and young people with special educational needs
DfE should: i) improve the data, incentives and processes to ensure children's needs are identified and supported as early as possible, particularly within early years
Accepted
The effectiveness of government in tackling homelessness
We recommend that DLUHC should consider how it can support local authorities to focus more on homelessness prevention.
Accepted
Tackling serious and organised crime
The Department should continue to support organisations to tackle the underlying causes of serious and organised crime. In 2015-16, 4% of the front-line spending on tackling serious and organised crime was estimated to have been spent on Prevent activities, compared …
Accepted
PHSO ombudsman recommendations(1)
IMB individual recommendations(94)— showing 50 strongest matches
Wandsworth (2020)
The poor quality of the resettlement provision continued to be of serious concern. What is being done to improve this?
HMPPS
In Progress
Swaleside (2020)
In our report last year, we mentioned that it is essential that residents are provided with resettlement services, preferably in a prison nearer to their home as they reach the end of their sentences. This service has not been provided from Swaleside. Though there were only 17 residents released from the prison in the last year, none of them were …
HMPPS
In Progress
Bristol (2020)
The Ministry of Justice should review the cases of certain prisoners coming into prison for minor offences because there is nowhere else in the community for them to go, and where their outcomes may be better if they are supported in the community or through more specialist placements.
Ministry of Justice
In Progress
The Mount (2023)
Education programmes have not improved during the reporting period, due to the lack of investment. Too few prisoners are enabled to access programmes to help them on release. During the year 50% of workshops stood empty due to the lack of instructors or any meaningful activities leading to qualifications to improve employment opportunities on release.
HMPPS
The Mount (2023)
The Board is concerned that, as a training and resettlement prison, the prison is failing to provide meaningful education, employment and training. This is made worse by the prison having a number of short-term prisoners arriving. Too many prisoners are released before completing their offending behaviour programmes and with no accommodation on release.
Ministry of Justice
Ford (2025)
The cuts to the education budget have had a significant impact on Ford’s ability to provide purposeful activity in support of the core reducing reoffending objective for Ford. Will HMPPS commit to restoring the education budget at HMP Ford to a level that enables the prison to deliver both meaningful education and skills provision?
HMPPS
Rejected
Hewell (2022)
The Prison Service, working with the Probation Service, should place more emphasis on therapeutic interventions to address longstanding trauma, neurodiversity and social/psychological problems of prisoners. Too many come into the prison and leave without any intervention; this mitigates against successful resettlement and reduction in reoffending. It is not enough to pin change on the introduction of key work delivered by …
HMPPS
In Progress
Warren Hill (2023)
The prison has prioritised the need to ensure support for prisoners on release in order to reduce the recall rate. The IMB would like to see further development in this area, including the use of digital technologies which are so critical to successful functioning in the modern world.
Governor / Director
The Mount (2023)
There needs to be a complete overhaul of the use of the workshops and how they can better serve the needs of prisoners in terms of training and future employment.
HMPPS
Swansea (2023)
Post-release accommodation remains a significant problem. We understand this is not an issue that can be easily resolved but would like to see the targeting of funding towards the resolution of this particular problem. The Board is very clear in its view that lacking a ‘roof over your head’ is a major contribution to reoffending.
Other
In Progress
Lowdham Grange (2023)
To ensure that high-quality and innovative programmes of rehabilitation, mental health provision, education, skills development and self-improvement are available for all prisoners. This must include defined standards and the minimum number of programmes to be delivered.
HMPPS
Lowdham Grange (2023)
To give priority in the matter of resourcing the probation services with regard to pre-release management and to support for prisoners after their release back into the community.
HMPPS
Doncaster (2024)
The lack of adequate probation and community support for prisoners being released into the community is negatively impacting on prisoners who, without the necessary accommodation and support, are at a greatly increased chance of them returning to prison. The Board requests that resources, necessary within the community to ensure that those released have the opportunity to rehabilitate into society and …
HMPPS
In Progress
Brixton (2024)
HMP Brixton is the final stage in a chain of reception/training/resettlement prisons; but population pressures ‘upstream’ have led to the ‘inappropriate’ sort of prisoner arriving in Brixton, one who has unaddressed issues and insufficient sentence time remaining to resolve them. This means that they leave Brixton ill-equipped to avoid reoffending. How does the Minister plan to change this?
Ministry of Justice
In Progress
Aylesbury (2024)
Prioritise pre-release welfare and employment planning by establishing and funding stronger statutory links between prisons, external agencies offering ex-offender support, and employers.
Ministry of Justice
In Progress
Lancaster Farms (2020)
The Board remains disappointed that constraints placed upon the Governor result in ROTL is rarely used, despite the designation of the establishment as a resettlement prison (see paragraph 11.5).
HMPPS
Rejected
Lancaster Farms (2020)
The Board believes that the monitoring of resettlement would be enhanced by having access to data, and cooperation from all the agencies with resettlement responsibilities, both inside the prison and in the community (see paragraph 11.1).
Ministry of Justice
Implemented
Hull (2020)
Improving the initial education assessments to overcome the disengagement that leads some prisoners into reoffending.
HMPPS
In Progress
Hull (2020)
Develop better feedback on prisoners’ after release so that prisons can see whether their resettlement straegies are working.
Ministry of Justice
In Progress
Whatton (2021)
Will the Prison Service review, with other agencies, the timely notification of approved premises for released prisoners, to give them the best chance of resettlement and rehabilitation?
HMPPS
In Progress
Wayland (2021)
The Board believes that, despite the challenges, there should be a serious attempt to identify those with the greatest need for resettlement assistance and do what is possible to provide this and so recommends to the Prison Service (see section 7.3).
HMPPS
In Progress
Hindley (2021)
As raised last year, Covid-19 and the introduction of new contracts have had a negative impact on the information advice and guidance available to men prior to and on release. Resolving this now needs to be a priority to ensure prisoners receive comprehensive support at this time of potential vulnerability.
Governor / Director
Bedford (2021)
It is very surprising that the removal of the community rehabilitation companies (CRCs) and the reintegration of probation services in June 2021 could not be coordinated with the letting of new finance, debt and benefits contracts, which, we understand, will not be in place until February 2022, some eight months later. Without support in these key areas, released prisoners are …
HMPPS
In Progress
Thameside (2022)
Work with other government departments to provide sufficient resources so that prisoners have adequate resettlement support and guidance on release such as housing and employment which is known to reduce recidivism.
Ministry of Justice
Thameside (2022)
Provide sufficient resourcing for the probation service to ensure adequate support to both sentenced and remand prisoners before and after their release.
Ministry of Justice
Portland (2022)
Will HMPPS consider reverting to a properly-funded resettlement service based within each establishment? How will HMPPS ensure that the implementation of new policies and systems is well managed and delivered in a way that does not adversely impact on the safety, fair and humane treatment, health and wellbeing and progression towards a successful resettlement of all those entrusted to its …
HMPPS
Lowdham Grange (2022)
To give priority to resourcing of probation services to the required levels within the prison estate and in the community, so that prisoners have adequate support and guidance before and after their release.
HMPPS
In Progress
Durham (2022)
What can be done to give remand prisoners access to probation services prior to release (7.5.2)?
HMPPS
Whatton (2023)
Will the Prison Service ensure that adequate funding is made available to HMP Whatton to provide for effective and meaningful resettlement training for its prisoners approaching release?
HMPPS
In Progress
Styal (2023)
What financial support can be given for pre-release planning for remand prisoners? Currently in Styal, basic services are provided but there is no funding for these, nor is there funding for the level of service available to sentenced prisoners.
Ministry of Justice
Wandsworth (2024)
Will the Remand Project continue to be funded? Are there any other initiatives in place to assist the rehabilitation of remand prisoners?
Ministry of Justice
In Progress
Swinfen Hall (2024)
Can HMPPS provide funding to support HMP Swinfen Hall with the release of prisoners, bearing in mind that the prison currently has no funding to support prisoners on release and some 80 prisoners are expected to be released directly from the prison in the coming year?
HMPPS
Implemented
Stoke Heath (2024)
Can the prison be creative in finding more places for prisoners to be trained or employed and less time in their cells?
Governor / Director
Stoke Heath (2024)
It would be encouraging if men in resettlement prisons could be actively engaged in resettlement activities, i.e. they should spend less time in their cells and more in purposeful work and training for vocational qualifications.
Ministry of Justice
Stoke Heath (2024)
The Minister should arrange for appropriate resourcing to prevent overcrowding and allow the means to educate and provide skills to reduce reoffending.
Ministry of Justice
Send (2024)
The initiative to tackle obesity in prisoners needs to be followed through.
Governor / Director
Lincoln (2024)
What support can be provided to help remand prisoners with release planning, as they are not eligible for probation services?
HMPPS
In Progress
Isis (2024)
What plans are there for a strategy that aims to reduce violence among young offenders in the community before they are sentenced, after sentencing and after their sentence is over?
Ministry of Justice
In Progress
Hewell (2024)
Will the Minister extend support for prisoners after release to reduce recall and re-offending?
Ministry of Justice
Noted
Elmley (2024)
Improve funding for vocational work-based opportunities for prisoners to support effective transition back into legitimate paid employment on release and promote greater opportunities for prisoners to directly improve their living environment.
HMPPS
In Progress
Bristol (2024)
There appears to be insufficient support for prisoners on release to prevent them returning to prison for short periods of time and/or being recalled due to relatively minor licence breaches. How will the Minister address this?
Ministry of Justice
In Progress
Thameside (2025)
The Director should consider reinstating the restorative justice post.
Governor / Director
East Sutton Park (2025)
Could the Prison Service work with closed women’s establishments to ensure that prisoners arriving at HMP ESP have a minimum of six months left to serve to enable them to benefit from release on temporary licence (ROTL) and be properly prepared for release and resettlement?
HMPPS
In Progress
Doncaster (2025)
In the Board’s view, the Probation Service nationally is critically understaffed and poorly managed, leaving people before and after release without proper support. This creates a ‘revolving door’ of reoffending and rising recidivism. What action will the Prison Service take to fix staffing and management so individuals get the support they need to break this cycle?
HMPPS
In Progress
Askham Grange (2025)
The Board looks forward to seeing what new developments there may be to ensure that prisoners get the best experience whilst at HMP/YOI Askham Grange to reduce re-offending and have a successful resettlement in the community on release.
Governor / Director
Noted
Brinsford (2023)
The length of time prisoners remain on remand before appearing in court continues to be too long. Prisoners are being released into the community following sentencing at court without attending any programmes to examine their offending.
Ministry of Justice
Standford Hill (2020)
We would again commend the work done on resettlement and its success in reducing reoffending after prisoners leave Standford Hill. We believe that the prison has the physical potential for expansion, so that this work could be capitalised on; however, the prison desperately needs its own kitchen facilities and the upgrading of cell block C before this can be achieved.
Other
In Progress
Portland (2020)
In order to maximise the opportunities for learning and change provided to prisoners while in custody, investment needs to be put into accommodation, employment and learning opportunities in the community post-release.
Ministry of Justice
In Progress
Hull (2020)
Develop the key worker scheme to better understand the needs of young adults making use of, for example, the maturity screening toolkit.
Governor / Director
Highpoint (2020)
JobCentrePlus withdrew all support from the prison in March 2020. The Board asks the minister to investigate this action, in light of the fact that other services were maintained across the estate by remote means. The continuation or return of Covid restrictions should not deprive those due for release of this vital support.
Ministry of Justice
In Progress
Health investigations(87)
Independent investigation: Richard Marden, Towcester (1999) — Rec 2
That, in accordance with Department of Health Guidance on CMHTs, set out in "Mental Health Policy Implementation Guide - Community Mental Health Teams" published in 2002, and in the light of the increasing demands from the Department of Health for documentation as well as its ambitions for early intervention in …
midlands
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 11
DPT will establish perinatal services to cover all areas of Devon and Torbay in accordance with commissioner requirements.
south_west
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 3
The Northumbria Local Criminal Justice Board should establish liaison with the criminal courts to ensure the effective use of Community Penalties, in order to strengthen the assessment, management and supervision of offenders in the community who have proved otherwise difficult to engage.
north_east_yorkshire
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 2
Notwithstanding the history in this case of Mark Towell’s failure to engage with the many agencies with which he came into contact, it is important that all organisations provide every opportunity for engagement. Agencies should regularly review their procedures so as to maximise the potential for engagement with reluctant clients …
north_east_yorkshire
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 1
Strategies should be developed within inter agency working to improve the understanding of domestic violence, often a hidden problem in society, in the management of risk within the community. These strategies should also deal with the well established links between domestic violence and child protection issues.
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 33
The Drug Action Team should ensure that substance misuse services develop interventions which attempt to maintain engagement with chaotic and risky patients, irrespective of whether the patient is committed to the therapeutic process (e.g. outreach services targeted at such people).
london
Independent investigation: Ian LawsonSimon Richardson, Sunderland — Rec 3
The inquiry panel recommends that service development in mental health should be supported and robustly monitored to ensure progress in line with national priorities. In particular alternative models which may aid the treatment of patients such as Sean Crone, including crisis intervention, early intervention in psychosis and assertive outreach teams …
north_east_yorkshire
Independent investigation: Asiya Khatun, Newham (2000) — Rec 20
East London and The City Mental Health NHS Trust and Newham Primary Care Trust should develop a programme of education and information on mental health policies, care and treatments, to reach faith communities and influential community groups; this should aim to foster a balanced appreciation of the issues of stigma …
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 17
The community services should focus on those with severe and enduring mental illness, with the development of early intervention and assertive outreach services.
north_west
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 2
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of community mental health services, including assertive outreach, home treatment, and early intervention services.
midlands
Independent investigation: Stephen Rees, Cardiff (2011) — Rec 3
The Health Board should review what arrangements it has in place in order to reduce the Duration of Untreated Psychosis (DUP)24. DUP can be reduced by the effective use of early intervention teams and by mental health promotion campaigns25.
wales
Independent investigation: Odessa Carey, Washington (2019) — Rec 4
a) The Home Office should incorporate learning about matricide and parricide into domestic abuse prevention strategies. b) Adult child to parent violence and mental illness should be incorporated into domestic abuse strategies.
north_east_yorkshire
Independent investigation: Odessa Carey, Washington (2019) — Rec 3
Northumberland County Council must ensure that a comprehensive domestic abuse strategy includes measurable outcomes from previous reviews.
north_east_yorkshire
Independent investigation: Matthew Carter, Tooting (2006) — Rec R1
The trust should continue to work towards the expansion of the EIS in line with the DH policy implementation guidance and the creation of a borough-based early intervention service.
london
Independent investigation: Leonie McGlashan, Wood Green (1995) — Rec 1
The East London and The City Health Authority should ensure that there is a clear and comprehensive Mental Health Strategy for Hackney. This should be based on a clear analysis and understanding of local needs and should establish agreed priorities which are then systematically and vigorously pursued.
london
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 29
Whilst acknowledging the planned benefits in ‘Protect Life – A Shared Vision’ – The Northern Ireland Suicide Prevention Strategy and Action Plan, 2006-2011 launched in October 2006, including its stated intention to provide support and assistance to families bereaved by suicide, we take the view that some of the proposed …
northern_ireland
Independent investigation: Hugh McCaffrey, Willesden — Rec 5.110
The eligibility criteria should be reviewed in line with available resources. There should be an acknowledgement that vulnerable adults may fall outside the service eligibility criteria and that alternative responses may need to be offered to meet their needs.
london
Independent investigation: Hugh McCaffrey, Willesden — Rec 5.51
An Assertive Outreach team should be established available to work with vulnerable people living in the community who are not deemed to be of high enough priority to qualify for an assigned social worker and who yet need support.
london
Independent investigation: Hugh McCaffrey, Willesden — Rec 5.50
The Eligibility Criteria should be reviewed in line with available resources. There should be an acknowledgement that vulnerable adults may fall outside such criteria and that alternative responses should be offered to meet their needs.
london
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015) — Rec 1
The RCGP and the Centre for Mental Health in England produced a report, ‘Falling through the gaps’ in 2015.15 This report highlights the role of GPs in disclosure, identification and support of women who develop a mental illness in the perinatal period. The recommendations are equally pertinent to Scotland and …
scotland
Independent investigation into the care and treatment of Christopher Stone-Houghton … — Rec 6
Access to Early Intervention in Psychosis services are reviewed in line with relevant NHSE and NICE guidance. Clinical protocols should be developed to facilitate access to services for individuals approaching 65 based on need rather than age.
Hampshire and Isle of Wight Healthcare NHS FT
south_east
An independent investigation into the care and treatment of a … — Rec 8
Services for young people, including schools and SaBP CAMHS services should raise awareness of inter relationship abuse amongst young people, and ensure that opportunities for education, support and disclosure are available.
south_east
A joint Domestic Homicide Review and Independent Investigation into the … — Rec 4
That Sefton Safer Communities Partnership undertakes research within its local communities about barriers to reporting domestic abuse and how the community can be empowered to ‘speak out’. Furthermore, Sefton Safer Communities Partnership is asked to develop, publish and publicise advice for family and friends on what to do [or not …
Sefton Safer Communities Partnership and Mersey Care NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of patient M … — Rec 98
The prime time for conveying this information is at reception into the prison; partly for the prisoner’s safety but also to promote the culture that help with substance misuse issues is available. Specific vulnerabilities which may predispose to using in prison (such as past behaviours, or current mood disorder) can …
east_of_england
Independent investigation into the care and treatment of patient M … — Rec 96
Education is the main preventative health intervention, especially in preventing the proportion of users who use NPS for the first time in prison. Topics include drug refusal skills, risks to physical and mental health, and the unpredictable effects of NPS compounds as they are composed of different types of substances …
east_of_england
Independent investigation into the care and treatment of Mr DB: … — Rec 5
Pennine Care NHS Foundation Trust : should ensure that NICE CG178 ( Psychosis and schizophrenia in adults: prevention and management) is implemented and monitored
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
Independent investigation into the care and treatment of Mr DB: … — Rec 20
Stockport NHS Foundation Trust : Fully implement NICE guidance ‘Domestic violence and abuse: multi-agency working’ (PH50) recommendation 5: ‘Create an environment for disclosing domestic violence and abuse’ with particular emphasis on consistent implementation of policy, and recording of information
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
Accepted
An independent investigation into the NHS care and treatment of … — Rec 1
EPUT must ensure that Early Intervention Services meet the expectations of best practice guidance and standards.
east_of_england
A Learning Lessons Bulletin on the care and treatment of … — Rec 5
Trusts should also work with faith communities to improve awareness of prevention and tackling domestic abuse, and to review the safeguarding approaches adopted by diverse faiths and places of worship.
london
A Learning Lessons Bulletin on the care and treatment of … — Rec 1
Trusts should develop a strategy which encapsulates the prevention, early intervention, partnership priorities and approaches to tackling domestic abuse when issues arise with service users.
london
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 28
The Home Office should incorporate learning about matricide and parricide into domestic abuse prevention strategies.
north_east_yorkshire
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 26
Safer Cumbria must develop and implement a comprehensive domestic abuse strategy which includes learning from this review.
north_east_yorkshire
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 23
Cumbria County Council must develop and implement employment policies to support routine enquiry about domestic abuse.
north_east_yorkshire
A Joint Domestic Homicide Review and independent mental health homicide … — Rec 22
NHS North Cumbria CCG must develop and implement policies to support routine enquiry by GPs about domestic abuse.
north_east_yorkshire
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.5
The Clinical Standards should be revised to include a process for referral of service users for psychological review and assessment.
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: Lynda Lovatt, South Shields (2004) — Rec 1
The alcohol issue There was evidence that two GPs in one practice in South Tyneside and a number of clinicians working in South Tyneside failed to understand the significance of alcohol dependency or misuse in the assessment and treatment of mental health issues. This may well reflect a general problem …
north_east_yorkshire
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec c.
That all local mental health services must have access to crisis teams and crisis residential alternatives to hospital admission, and that additional funding should be made available for this.
midlands
Independent investigation: Lenny Leak, Gateshead (2001) — Rec 4
Drug and alcohol misuse is a problem which presents itself to all agencies. The Panel recommends that the Drug Action Team reviews the policy and procedures of all agencies to ensure that there are pro-active and resilient services available for those with drug and alcohol problems. This review should include …
north_east_yorkshire
Independent investigation: Ian LawsonSimon Richardson, Sunderland — Rec 1
The inquiry panel recommends that mental health services in Sunderland develop a strategy which recognises the need to engage those individuals who are reluctant to access services. Within such a strategy, policies and procedures should be put in place, which allow the identification of those unwilling to work with services …
north_east_yorkshire
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 43
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients who are perpetrators of domestic violence receive appropriate intervention and support to address their behaviour.
midlands
Independent investigation: Wendy Pashley, Rotherham (2006) — Rec 3
Although it is not uncommon for mental health service users to have a higher alcohol intake than is recommended, the Trust needs to develop a more proactive approach to the education of its service users about excessive drinking and also information about local support groups if the service user and/or …
north_east_yorkshire
Independent investigation: Vincent Francis, Wells (2009) — Rec 1
The development of standardised tools which specifically measure alcohol/substance dependency should be promoted for common use in services when risk assessment indicates a problem with alcohol and substance misuse.
south_west
Independent investigation: Robert Lewis, Sutton (2010) — Rec One
It is recommended that the Trust considers how future services and clinical care pathways are established for adolescent substance misusers to address their needs, and that a report outlining appropriate plans to address this issue is presented to the executive committee.
london
Independent investigation: Odessa Carey, Washington (2019) — Rec 1
NHS Northumberland Clinical Commissioning Group must provide assurance that GP surgeries: a) Have the necessary knowledge and skills to recognise domestic abuse. b) Use the systems in place to recognise and act on disclosures of domestic abuse. c) Northumberland Clinical Commissioning Group should explore the inclusion of an established domestic …
north_east_yorkshire
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 35
DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland should commission UK wide research into all aspects of child killing to ensure that attention is given to increasing the understanding of cases involving parents who are mentally disordered but where there are no pre-existing child care concerns. This …
northern_ireland
Independent investigation: Jenny Bryant, Consett — Rec 1
This incident has highlighted a situation where vulnerable adult risk was assessed only in relation to the victim, and perpetrator risk was not considered. It is accepted that the safeguarding framework and guidance is victim focused; however, it is also noted that neither the framework nor the guidance was developed …
north_east_yorkshire
Independent investigation: Jayne Poppy, Leigh on Sea (2002) — Rec 4
The Trust should ensure that there is an Alert system for a client who may be disengaging from services.
east_of_england
Independent investigation: Hugh McCaffrey, Willesden — Rec 4.82
The Trust should consider the development of assertive outreach teams to access those patients who are seriously ill or unwilling/unable to access the conventional services.
london
Independent investigation: David Limb, Wath (2004) — Rec 4
The alcohol treatment service needs to reflect on its own documentation to determine whether by-and-large it is satisfied with its own standards of documentation, and that the documented contacts with its client group adequately reflect the ‘in the moment’ position for the service user in relation to their consumption of …
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
John Grant Cousin
[7] In terms of Section 26(1)(b), it is recommended that consideration be given to imposing a requirement (or advising through guidance) that a warning label should be attached to the pivot pin on cranes such as the one involved in the present case advising operators not to remove the pin without first having confirmed that the fly jib is secured …
Jan 2018
Scott James Rennie
In terms of section 26(1)(b) of the 2016 Act the court recommends: I. that fishermen involved in this type of scallop dredger fishing should avoid standing on the tipping door of the vessel whilst at sea to carry out repairs to dredge bags or for any other reason. A system of work should be devised to avoid the need for …
Oct 2019
Independent reviews(50)
Narey-Owers Foster Care Review — Rec 34
We believe that children on the edge of care and their families should routinely gain earlier access to foster care. The Department for Education, together with select local authorities and independent fostering agencies, should further explore the potential for support foster care as a means of: avoiding unnecessary entry into …
Other
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 12
The Department of Health should work with PHE to continue to support proven behaviour change interventions, such as Time to Change, and to establish Mental Health Champions in each community to contribute towards improving attitudes to mental health by at least a further 5 per cent by 2020/21. CHAPTER TWO: …
Health & Social Care
Mental Health Taskforce 2016 — Rec 3
The Department of Health, PHE and NHS England should support all local areas to have multi-agency suicide prevention plans in place by 2017, reviewed annually thereafter and supported by new investment.
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
Harris Review: Deaths in Custody — Rec 45
Further funding should be made available by the Department of Health to CAMHS services (and Welsh Government equivalent) to ensure early identification of mental health issues that, if properly supported, can be dealt with more effectively at an early age. CAMHS services need to be more closely linked to educational …
Justice & Legal
Harris Review: Deaths in Custody — Rec 44
There should be a parallel Programme focussing on the needs of vulnerable young people who are at risk of entering or already have had a number of encounters with the criminal justice system.
Justice & Legal
Harris Review: Deaths in Custody — Rec 43
The scope of the Troubled Families Programme should be expanded to address early family intervention. The Welsh Government should be invited to expand their own programmes to address the same issue.
Justice & Legal
Building Better Building Beautiful Commission — Rec 29
clean urban air. As the data on poor air quality in our towns and cities becomes clearer and as the effect this has on people’s health becomes better understood, there is a seismic shift in attitudes taking place. We are encouraged by the recent Environment Bill and encourage the government …
Building Safety
Dimbleby National Food Strategy — Rec 3
Launch a new "Eat and Learn" initiative for schools.
Health & Social Care
Laming Review (Baby P) — Rec 55
The Department for Children, Schools and Families must sufficiently resource children's services to ensure that early intervention and preventative services have capacity to respond to all children and families identified as vulnerable or 'in need'.
Other
Laming Review (Baby P) — Rec 14
Local authorities must ensure that 'Children in Need', as defined by Section 17 of the Children Act 1989, have early access to effective specialist services and support to meet their needs.
Other
Narey Review of Children's Residential Care — Rec 15
The Department for Education and the Home Office should urge police services and local authorities to replicate the south-east protocol, or to agree similar arrangements. And, where they are not already doing so, to apply a restorative justice approach in dealing with children's unacceptable behaviour.
Other
Wood Review of LSCBs — Rec 10
The role of schools in providing early help to children and young people should be included in the Department for Education's review of the role of a local authority in education. This should include the role of the police and health services.
Other
O'Neill AMR Review — Rec 6
Promote the development and use of vaccines and alternatives 6.1 Promote the uptake and use of existing vaccines more widely in humans and animals to save lives and reduce unnecessary antibiotic use, including through the work of Gavi or by initiating comparable new initiatives. 6.2 Sustain a viable market for …
Health & Social Care
O'Neill AMR Review — Rec 1
A massive global public awareness campaign 1.1 With leadership from an appropriate global body, establish an internationally-coordinated public awareness campaign to improve public understanding of the problems of drug resistance and support positive behaviour change regarding antibiotic use. Whilst globally consistent in its overall message, this should be delivered at …
Health & Social Care
Black Review on Health and Work — Rec 17
Government should accelerate and broaden its work in applying the 'Healthy Schools' approach to further education to create expectations among new entrants to the workforce on the health and well-being support employers should offer.
Health & Social Care
Black Review on Health and Work — Rec 7
Government should pilot a new Fit for Work service based on case-managed, multidisciplinary support for patients in the early stages of sickness absence, with the aim of making access to work-related health support available to all – no longer the preserve of the few. Pilots should test various models of …
Health & Social Care
Black Review on Health and Work — Rec 4
Government should launch a major drive to promote understanding of the positive relationship between health and work among employers, healthcare professionals and the general public. This should include encouraging young people to understand the benefits of a life in work and its impact on their families and communities.
Health & Social Care
Black Review on Health and Work — Rec 3
Government should initiate a business-led health and well-being consultancy service, offering tailored advice and support and access to occupational health support at a market rate. This should be geared towards smaller organisations. It should aim to be self-sustaining in the medium-term, and be fully evaluated and tested against free-to-use services.
Health & Social Care
Allen Early Intervention Review (Part 1) — Rec 33
A further report on the Financing of Early Intervention is being prepared by my team and I recommend that the Cabinet Social Justice Committee should ensure that the team is properly resourced and staffed to enable the report to be presented before the Parliamentary summer recess.
Other
Allen Early Intervention Review (Part 1) — Rec 31
I recommend that the successful interaction begun by the review with local government should be continued and developed, especially by giving local government a leading role in the Early Intervention Foundation.
Other
Allen Early Intervention Review (Part 1) — Rec 30
As soon as ministers resolve their approach, I recommend that the commitment across government to Early Intervention should be given the strongest and most active leadership by the Permanent Secretaries Committee, especially on how to join up departmental thinking and delivery on Early Intervention, and in particular how to get …
Other
Allen Early Intervention Review (Part 1) — Rec 29
I recommend that the Cabinet Social Justice Committee should resolve the issue of future cross-government co-ordination on Early Intervention policy immediately on presentation of this Report.
Other
Allen Early Intervention Review (Part 1) — Rec 28
I recommend that all political parties should work together on the Early Intervention agenda. Even before the publication of this Report I wrote to all party leaders to ask that they continue to work – together where possible – on Early Intervention policies in the future in a way which …
Other
Allen Early Intervention Review (Part 1) — Rec 27
I recommend the immediate creation of a ‘shadow’ Early Intervention Foundation including those quoted in Annex A to bring these proposals to fruition over the next few months.
Other
Allen Early Intervention Review (Part 1) — Rec 26
I recommend that the Foundation should be given the following roles: • to lead and motivate the expansion of Early Intervention with initial emphasis on the 15 Early Intervention Places; • to evaluate Early Intervention policies on the basis of a rigorous methodology and a strong evidence base, and encourage …
Other
Allen Early Intervention Review (Part 1) — Rec 24
I recommend the establishment of an independent Early Intervention Foundation to support local people, communities and agencies, with initial emphasis on the 15 Early Intervention Places.
Other
Allen Early Intervention Review (Part 1) — Rec 22
I recommend that Early Intervention should build on the strength of its local base by establishing 15 local Early Intervention Places to spearhead its development. These should be run by local authorities and the voluntary sector, who are already the main initiators and innovators of Early Intervention.
Other
Allen Early Intervention Review (Part 1) — Rec 21
I recommend that a growing number of excellent well-regarded UK programmes should be assisted in joining the list as proven programmes able to help our children the most.
Other
Allen Early Intervention Review (Part 1) — Rec 20
I recommend that the 19 ‘top programmes’ identified in my Report should be supported and expanded to demonstrate our commitment to Early Intervention. However, I also recommend that this list of 19 should not be regarded as exhaustive or complete: all should be reviewed and reassessed by the new Early …
Other
Allen Early Intervention Review (Part 1) — Rec 18
I recommend that a greater proportion of any new public and private expenditure should be spent on proven Early Intervention policies rather than on unproven ones.
Other
Allen Early Intervention Review (Part 1) — Rec 17
I recommend a new National Parenting Campaign as the Crown Jewel of the Big Society project, pursued with enough passion and vitality to make it irresistible even to the most jaundiced. I recommend the creation of a broad-based alliance of interested groups, charities and foundations to ensure that the public, …
Other
Allen Early Intervention Review (Part 1) — Rec 15
I recommend that all children should have regular assessment of their development from birth up to and including 5, focusing on social and emotional development, so that they can be put on the path to ‘school readiness’ which many – not least from low-income households – would benefit from. Accountability …
Other
Allen Early Intervention Review (Part 1) — Rec 13
I recommend that future expansion of Early Intervention programmes should favour those which combine strong evidence bases with impact on crucial stages in the development of social and emotional bedrock in children, and that the present national network of children’s centres should use such approaches, including evidence- based evaluation systems, …
Other
Allen Early Intervention Review (Part 1) — Rec 12
I recommend that the success of Family Nurse Partnership should be taken further, with the aspiration that every vulnerable first-time young mother who meets the criteria and wants to join Family Nurse Partnership should be able to access it, and that discussions should take place with all relevant interests on …
Other
Allen Early Intervention Review (Part 1) — Rec 10
I believe that under the Government’s proposed new arrangements for local health services, a great opportunity exists to localise Early Intervention, and I recommend that one of the reorganisation’s key themes should be a focus on antenatal education/preparation for parenthood, and on social and emotional development for the under-3s. I …
Other
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
Allen Early Intervention Review (Part 1) — Rec 8
Since a successful Early Intervention approach requires sustainability and a long-term view, I recommend that consideration should be given to creating a lasting, stable settlement between central and local government within a published framework or codification of the local/central relationship. I further recommend that, if developed, this settlement should be …
Other
Allen Early Intervention Review (Part 1) — Rec 7
I recommend that the United Kingdom should adopt the concept of the foundation years from 0 to 5 (including pregnancy), and give it at least the same status and recognition as primary or secondary stages. Its prime objective should be to produce high levels of ‘school readiness’ for all children …
Other
Allen Early Intervention Review (Part 1) — Rec 6
Since waiting for problems to take root before reacting costs the taxpayer billions of pounds, I recommend that we should exploit the potential for massive savings in public expenditure through an Early Intervention approach.
Other
Allen Early Intervention Review (Part 1) — Rec 5
I recommend proper co-ordination of the machinery of government to put Early Intervention at the heart of departmental strategies, including those seeking to raise educational achievement and employability, improve social mobility, reduce crime, support parents and improve mental and physical health.
Other
Allen Early Intervention Review (Part 1) — Rec 4
Within that context, I recommend an essential shift to a primary prevention strategy which offers substantial social and financial benefits.
Other
Allen Early Intervention Review (Part 1) — Rec 3
I recommend a rebalancing of the current culture of ‘late reaction’ to social problems towards an Early Intervention culture, based on the premise of giving all children the social and emotional bedrock they need to achieve and to pre-empt those problems.
Other
Allen Early Intervention Review (Part 1) — Rec 2
I recommend that the nation should recognise that influencing social and emotional capability becomes harder and more expensive the later it is attempted, and more likely to fail.
Other
Allen Early Intervention Review (Part 1) — Rec 1
I recommend that the nation should be made aware of the enormous benefits to individuals, families and society of Early Intervention – a policy approach designed to build the essential social and emotional bedrock in children aged 0–3 and to ensure that children aged 0–18 can become the excellent parents …
Other
Tickell Review of the EYFS — Rec 8
Recognising that there will be less support in the future to help early years providers improve, the EYFS must be redrafted in such a way that the framework is easy to access, understand and navigate, incorporating what is known about how young children learn and develop and highlighting the importance …
Education
Field Review on Poverty and Life Chances — Rec 16
The initiatives for the wider society should be taken up by the Behavioural Insight Team based in the Cabinet Office. This Review recommends that it leads, along with key Departments, an examination of how parenting and nurturing skills can be promoted throughout society.
Other
Marmot Review — Rec 6
Policy Objective F: Strengthen the role and impact of ill-health prevention Priority objectives: 1. Prioritise prevention and early detection of those conditions most strongly related to health inequalities. 2. Increase availability of long-term and sustainable funding in ill health prevention across the social gradient. Policy recommendations: 1. Prioritise investment in …
Health & Social Care
Allen Early Intervention Review (Part 2) — Rec 19
I recommend that when the Early Intervention Foundation is in place, it initiates serious all-party discussions on Early Intervention to agree on actions to maintain and promote long-term commitment to Early Intervention.
Other
PHSO casework decisions(12)
P-001359 — A medical practice in the Reading area
Mr U complained his diabetic medication was stopped, his diabetes was not properly monitored, eyesight concerns were ignored, and his COVID-19 vaccine was delayed.
NHS in England
Upheld
Apr 2022
P-001781 — A practice in the Plymouth area
Mrs E complained the Practice negligently prescribed quinine sulphate without monitoring and an unnecessary duplicate medication, leading to her mother's hospitalisation, injury, and decline.
NHS in England
Feb 2023
P-001895 — A practice in the Bury area
Mrs R complained the Practice failed to timely prescribe fluoxetine for her tics, body jerks, facial drooping, and fatigue, causing unnecessary suffering for three years.
NHS in England
Mar 2023
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-004413 — A practice in the West Suffolk area
A man complained his late wife was not referred for an X-ray and was repeatedly misdiagnosed, delaying her diagnosis and treatment for cancer.
NHS in England
Dec 2025
P-001806 — A practice in the West Midlands area
Ms O complained her mother, Ms I, was not properly treated by the Practice, failing to refer her for specialist support or section her, leading to her death from severe malnutrition.
NHS in England
Feb 2023
P-003906 — A practice in the Doncaster area
Ms L complained her GP practice failed to treat DVT, mental health issues, stomach problems, diabetic symptoms, menopause symptoms, and hypermobility over many years, significantly impacting her life.
NHS in England
Jul 2023
P-004475 — A practice in the South Gloucestershire area
Miss X complains the Practice failed to diagnose her daughter's pneumonia and fluid on her lungs in November 2024, despite ongoing symptoms, leading to serious illness.
NHS in England
Not Upheld
Dec 2025
P-003005 — A practice in the Exeter area
Miss O complained the Practice delayed timely specialist support for her mother, that a doctor was unprofessional, and that the complaint was improperly handled, contributing to her mother's deterioration and death.
NHS in England
Sep 2024
P-002915 — A practice in the Birmingham area
Mr A complained the Practice failed to schedule his wife's annual flu vaccination, leading to her contracting flu and pneumonia, which caused her death.
NHS in England
Sep 2024
P-004358 — Midlands Partnership University NHS Foundation Trust
The Trust wrongly blamed Miss K's mental health for A's difficulties and refused autism assessment (2014-2018), causing distress and delayed support.
NHS in England
Nov 2025
P-004359 — Midlands Partnership University NHS Foundation Trust
The Trust refused to acknowledge B's severe developmental delays or assess for autism (2018-2019), leading to distress and a delayed diagnosis.
NHS in England
Nov 2025
LGO / SPSO decisions(48)
21-010-585 — Bristol City Council
Summary: Mr X complained the Council was taking too long to investigate complaints about unlawful houses in multiple occupation (HMOs) in its area. We found fault because there was unreasonable delay in enforcement investigations. The Council has agreed to a remedy, to resolve the injustice caused by the fault we …
LGO (Local Government & …
Planning
Upheld
Mar 2022
21-012-092 — Stockton-on-Tees Borough Council
Summary: The Council failed to properly consider Mrs X’s application for a blue badge and failed to offer her the opportunity to appeal its decision.
LGO (Local Government & …
Adult Care Services
Upheld
May 2022
21-006-136 — Westminster City Council
Summary: Ms T complains that the Council has not taken the necessary action to address her concerns about anti-social behaviour from a café near to her home. She says this is having a negative effect on her life and her property has been targeted by the perpetrators. We find fault …
LGO (Local Government & …
Environment And Regulation
Upheld
Apr 2022
23-014-194 — Dorset Council
Summary: Mrs E complains her son’s school was following an out-of-date Education, Health and Care Plan. We uphold her complaint due to fault by the Council in its actions around this. Mrs E also complains about the school’s actions around a teacher’s use of language, inappropriate emails and suspensions of …
LGO (Local Government & …
Education
Upheld
Aug 2024
24-002-218 — Wirral Metropolitan Borough Council
Summary: Miss X complained about the Council’s delay completing her child, Y’s Education, Health and Care needs assessment. We find fault, causing injustice to Y and avoidable distress and uncertainty to Miss X. The Council has agreed to apologise and make a payment to Miss X.
LGO (Local Government & …
Education
Upheld
Aug 2024
23-020-681 — Suffolk County Council
Summary: We found fault in the way the Council carried out an Education Health and Care needs assessment for the complainant’s (Mrs X) daughter (Y) and in the Council’s communication with Mrs X. This fault caused Y and Mrs X injustice.
LGO (Local Government & …
Education
Upheld
Aug 2024
23-019-057 — London Borough of Wandsworth
Summary: HOS found the Council has provided reasonable redress for Ms X’s complaint regarding works to her kitchen. LGSCO did not find fault in how the Council assessed whether Ms X’s property could be adapted to meet her needs. LGSCO found fault in how the Council decided Ms X’s priority …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
23-018-792 — Liverpool City Council
Summary: There was delay by the Council in agreeing and putting in place transport for Y’s college placement and lateness by the taxi the Council commissioned. This caused avoidable distress, inconvenience and missed education. The Council will apologise and make payments.
LGO (Local Government & …
Education
Upheld
Aug 2024
23-018-774 — Liverpool City Council
Summary: There was a delay issuing Y’s final Education, Health and Care Plan naming his post 16 college placement. This caused avoidable distress, inconvenience and a delay in appeal rights. The Council will apologise, make symbolic payments and review its procedures to minimise the chance of recurrence.
LGO (Local Government & …
Education
Upheld
Aug 2024
201404348 — South Lanarkshire Council
Mr C complained about how the council handled his concerns about nuisance and anti-social behaviour. He had complained about damage to common areas, noise nuisance and the keeping of chickens which he believed attracted vermin. We found that the council followed their policy when Mr C reported neighbour nuisance and …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Mar 2015
202303409 — West Dunbartonshire Council
C complained that the council failed to deal with concerns that they raised about alleged anti-social behaviour (ASB) involving a neighbour. During our investigation, we considered whether or not the council had followed their anti-social behaviour policy (ASB policy) in relation to their handling of C’s concerns. We found that …
SPSO (Scottish Public Se…
Local Government
Upheld
Jun 2025
21-010-089 — Middlesbrough Borough Council
Summary: Mr X complained the Council failed to properly investigate anti-social behaviour from his neighbour. The Council was at fault for failing to consider all available options, for delaying looking into support for the alleged perpetrator, and for failing to regularly send Mr X’s CCTV evidence to the estate agent …
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2022
23-018-415 — Bristol City Council
Summary: Ms X complained about the way the Council dealt with her reports of anti-social behaviour. The Council failed to properly monitor and keep Ms X updated on the actions of the ASB case review. The Council’s complaint handling and communication was also inadequate. These faults caused Ms X distress, …
LGO (Local Government & …
Environment And Regulation
Upheld
Aug 2024
201005261 — Dundee City Council
Mr C lived in a sheltered housing complex. He complained that the council wrongly cautioned him about antisocial behaviour after a complaint was made against him that claimed he was responsible for noise nuisance. We found, from looking at the information provided by Mr C and at the council's records, …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Jun 2012
201305629 — The City of Edinburgh Council
Mrs C's neighbour is a council tenant living in temporary accommodation. Mrs C said that the tenant was noisy on a number of occasions, and she was unhappy with the council's response to the problem. She complained that the council were not dealing with this effectively, and that a housing …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Jul 2014
201608278 — Falkirk Council
Ms C is a council tenant and she reported a number of incidents of her neighbour's anti-social behaviour to the council. Ms C complained that the council failed to address her complaints about her neighbour's anti-social behaviour within a reasonable timescale. The council advised Ms C they can only investigate …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2017
201608217 — North Lanarkshire Council
Mr C complained about the council as he felt that they had failed to appropriately investigate reports of anti-social behaviour he and his wife had made about their previous neighbour. He claimed that the council had failed to liaise with Police Scotland over charges brought against the neighbour and that …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2017
201602803 — South Lanarkshire Council
Miss C complained about the way the council dealt with her complaint to them. She was also was unhappy that the council had issued warnings following an investigation into allegations of anti-social behaviour. We were satisfied that the council demonstrated that a fair and balanced investigation into complaints of anti-social …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Nov 2017
201805833 — North Lanarkshire Council
Mr C complained that the council had unreasonably acted in contravention of the title deeds of his property, that they had unfairly discriminated against him and his family and that they had failed to investigate his complaints over six months. We found that the council had taken reasonable steps to …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Mar 2020
202407333 — North Glasgow Housing Association Ltd
C complained that the association did not reasonably address reports of antisocial behaviour. C is the Chief Executive of a charity who owns a property in a block where other properties are owned by the association. The charity's tenant complained of antisocial behaviour from one of their neighbours and the …
SPSO (Scottish Public Se…
Local Government
Upheld
Dec 2025
25-013-384 — Mansfield District Council
Summary: We will not investigate this complaint about the Council’s response to reports of antisocial behaviour. This is because there is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Environment And Regulation
Feb 2026
25-013-070 — London Borough of Hackney
Summary: We will not investigate this complaint about the Council’s failure to install CCTV at Mr X’s request. This is because an investigation would be unlikely to find fault with the Council’s actions.
LGO (Local Government & …
Environment And Regulation
Feb 2026
25-005-573 — Milton Keynes Council
Summary: There is no evidence of fault in the Council’s decision not to enforce an abatement notice, which it issued after establishing a statutory noise nuisance. And we cannot investigate a complaint about the Council’s decision not to evict its tenant for causing the nuisance, because the law does not …
LGO (Local Government & …
Environment And Regulation
Not Upheld
Feb 2026
21-015-886 — Leeds City Council
Summary: Mrs X says the Council’s delay in investigating her complaint led to a company going into liquidation. This means she cannot get her money back. The Council is at fault because of the delays in its response. However, this failing did not cause Mrs X significant personal injustice which …
LGO (Local Government & …
Environment And Regulation
Upheld
Mar 2022
24-004-655 — Wakefield City Council
Summary: We will not investigate this complaint about the Council’s handling of Ms X’s report of anti-social behaviour by a person who is a neighbour of family members. This is because there is no evidence to suggest fault by the Council sufficient to warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Aug 2024
23-021-006 — Milton Keynes Council
Summary: We will not investigate this complaint about the Council’s failure to take sufficient action against a council tenant who Mr X says is causing noise nuisance and anti-social behaviour. We cannot investigate complaints about the management of tenancies by social housing landlords.
LGO (Local Government & …
Environment And Regulation
Aug 2024
24-005-999 — Torbay Council
Summary: We will not investigate this complaint about the Council’s handling of reports of neighbour anti-social behaviour (ASB) and nuisance made by Mr X. This is because an investigation is unlikely to add to that already carried out by the Council or lead to a significantly different outcome.
LGO (Local Government & …
Environment And Regulation
Aug 2024
23-017-648 — South Kesteven District Council
Summary: We will not investigate this complaint about anti- social behaviour. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. This is an ongoing case being investigated by the Council so there is no worthwhile outcome to …
LGO (Local Government & …
Environment And Regulation
Aug 2024
24-005-184 — London Borough of Enfield
Summary: We will not investigate this complaint about a Fixed Penalty Notice for fly tipping. This is because the complainant could have raised a defence in court.
LGO (Local Government & …
Environment And Regulation
Aug 2024
24-004-766 — Stoke-on-Trent City Council
Summary: We will not investigate this complaint about the Council’s handling of Miss X’s reports of noise nuisance. This is because we are unlikely to find evidence of fault by the Council sufficient to warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Aug 2024
24-020-850 — Manchester City Council
Summary: Mr X complained the Council repeatedly missed waste collections from his property and failed to deal with reports of fly-tipping and stolen bins, causing frustration and distress. We found the Council at fault, and it agreed to apologise and make payments for the distress it caused. We also found …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
24-019-295 — St Albans City Council
Summary: We will not investigate this complaint about the Council’s investigation into an alleged statutory nuisance from a neighbouring business. This is because
LGO (Local Government & …
Environment And Regulation
Sep 2025
25-007-962 — Royal Borough of Kingston upon Thames
Summary: We will not investigate Ms Z’s complaint about how the Council has handled her noise complaints since 2023. Part of the complaint is late. There is not enough evidence of fault and an investigation would be unlikely to lead to a different outcome.
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-007-136 — Stevenage Borough Council
Summary: We will not investigate Mr X’s complaint about how the Council has dealt with his concerns about a development near his home. There is not enough evidence of fault on how the Council investigated Mr X’s concerns to justify our involvement. Mr X has also raised concerns that fall …
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-004-556 — Stafford Borough Council
Summary: We will not investigate this complaint about a missed refuse collection. This is because the injustice is not significant enough to justify investigation.
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-005-845 — Dartford Borough Council
Summary: We will not investigate this complaint about the Council’s handling of its garden waste and general refuse collection services. There is insufficient evidence of fault, and we cannot achieve the outcome the complainant is seeking.
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-010-062 — Birmingham City Council
Summary: We will not investigate Mr X’s complaint about the Council’s failure to collect waste bins due to industrial action. This is because we have no jurisdiction to investigate matters which affect all or most people in the Council’s area.
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-001-904 — London Borough of Lambeth
Summary: We will not investigate this complaint about how the Council responded to a noise nuisance concern. This is because
LGO (Local Government & …
Environment And Regulation
Oct 2025
25-006-455 — Reading Borough Council
Summary: We will not investigate this complaint that the Council refuses to consider Mr X’s ongoing complaints about noise nuisance from his neighbour. This is because we are unlikely to find enough evidence of fault by the Council to warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Nov 2025
24-014-369 — Norwich City Council
Summary: We will not investigate this complaint about the advice provided by the Council’s pest control service. This is because there is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Environment And Regulation
Nov 2024
24-014-470 — City of Bradford Metropolitan District Council
Summary: We will not investigate this complaint about the Council’s decision that the complainant must pay to replace bins that were stolen. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Dec 2024
24-014-099 — City of Bradford Metropolitan District Council
Summary: We will not investigate this complaint about the time taken by the Council to deliver bins to the complainant. This is because there is insufficient evidence of injustice.
LGO (Local Government & …
Environment And Regulation
Dec 2024
24-005-529 — Cumberland Council
Summary: Miss X complains about a lack of action from the Council following its decision to issue an Abatement Notice to her neighbour. We have concluded our investigation having made a finding of fault. The evidence demonstrates excess delay in reaching a decision on what further action to take, if …
LGO (Local Government & …
Environment And Regulation
Upheld
Dec 2024
201501711 — West Lothian Council
Mr C, who is a council tenant, complained to us about two issues regarding reports he had made to the council about the anti-social behaviour of his neighbour. Firstly, he complained that the council failed to follow their policies and procedures by deciding not to investigate his reports. We found …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2015
201404811 — South Lanarkshire Council
Mrs C complained about the council's handling of complaints about some of their tenants in a neighbouring property, which was used by the council to temporarily house homeless households from 2011 to 2014. Mrs C complained about the way her complaints were handled by the council and, in particular, that …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Nov 2015
25-008-206 — Wakefield City Council
Summary: We will not investigate this complaint about the Council’s response to reports of antisocial behaviour. This is because there is not enough evidence of fault to justify our involvement.
LGO (Local Government & …
Environment And Regulation
Dec 2025
25-004-995 — Coventry City Council
Summary: We will not investigate this complaint about the Council’s decision not to investigate Mrs Y’s complaint about trading standards enforcement. The complaint is late and there is no good reason why it could not have been made sooner.
LGO (Local Government & …
Environment And Regulation
Aug 2025
24-014-958 — Bedford Borough Council
Summary: We will not investigate this complaint about a taxi licence decision. This is because the complaint is late and there are not good reasons to investigate the complaint now.
LGO (Local Government & …
Environment And Regulation
Nov 2024
Domestic Homicide Reviews(1692)— showing 50 strongest matches
Tewkesbury — recommendation 17.8.1
That MARAC meetings are held within 48 hours of any incident where possible to ensure early intervention. (This is now the agreed protocol)
Gloucestershire Multi-Agency Risk Assessment Conference
Tewkesbury — recommendation 17.6.1
That DASHs are sent through to GDASS as quickly as possible to enable contact with the victim to be made quickly after the event when they are most vulnerable.
Gloucestershire Domestic Abuse Support Service | …
Gloucestershire Constabulary
Tewkesbury — recommendation 17.2.1
A public awareness campaign should be rolled out encouraging third parties including friends and family aware of domestic abuse to contact the police and/or independent local specialist support services.
Gloucestershire Domestic Abuse and Sexual Violence …
Rotherham — recommendation 17.6
The Safer Rotherham Partnership ‘near miss’ policy should be updated to require immediate notification to the DAPG via the DAC rather than delaying referrals to the next scheduled meeting.
Safer Rotherham Partnership
Rotherham — recommendation 17.5
The Safer Rotherham Partnership is well aware that raising public awareness of domestic abuse is an on-going process. The partnership should be clear that Domestic Abuse is wider than physical violence and should include all types of abuse, including coercive control. It should also include that abuse is age neutral …
Safer Rotherham Partnership
Rotherham — recommendation 17.2
The Home Office is invited to consider the current ‘near miss’ policy identified by the Safer Rotherham Partnership for wider dissemination and implementation.
Home Office
Home Office
Rotherham — recommendation 17.1
Consideration should be given to the national guidance for reporting gunshot and knife injuries without the consent of the victim being reviewed with a view to including life threatening injuries caused by other means.
Government (National)
Bury — recommendation 3.
GP practices to be encouraged to raise awareness of domestic abuse and support services within their surgeries by the displaying of educational posters and leaflets. This is also included in IRIS training.
North Manchester Clinical Commissioning Group
Bury — recommendation 3
That Team Bury Community Safety Partnership reviews whether its advice to family and friends who have knowledge of domestic abuse has penetrated the community effectively.
Team Bury Community Safety Partnership
Bromley — recommendation 4.5.8
That Her Majesty’s Prison Service recognises the importance of programmes for violent abusers, including those on short sentences, and reviews their capacity to deliver such programmes to take the opportunity to change perpetrators behaviours before release.
Her Majesty’s Prison Service
Bromley — recommendation 4.4.12
The CSP and safeguarding boards should work with partner agencies to organise public awareness campaigns to raise residents’ understanding of domestic abuse and publicise services: including what friends or family members can do if they are concerned about someone they know.
Bromley Community Safety Partnership | Bromley …
Kingston upon Hull — recommendation 14
The Trust is implementing a three-year ‘Routine Enquiry’ systematic roll out programme to areas not currently implementing ’Routine Enquiry’. This will be completed in or before 2021/2022
Hull and East Yorkshire Hospital Trust
Portsmouth — recommendation 12
Primary Care to consider a review of their routine screening questionnaires to ensure it includes a question relating to the patient experiencing domestic abuse.
GPs – Surgeries Portsmouth
Cheltenham — recommendation GHCNHST.1
Make every contact count - using opportunity for conversations about domestic abuse and exploring options and choice. Make efforts to seek consent to liaise with and involve family members if considered safe and potentially helpful to do so.
Gloucestershire Health and Care NHS Trust
Gloucestershire Health and Care …
Doncaster — recommendation 7
That Safer Stronger Doncaster Partnership ensures that there are services and referral pathways in place for perpetrators of domestic abuse, in particular, for those perpetrators who are not being managed within the criminal justice system.
Safer Stronger Doncaster Partnership
West Lancashire — recommendation 27
NHS Integrated Care Board (West Lancashire locality) to Develop a DA Grab pack which will be circulated to Primary Care services
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
Sheffield — recommendation 3
All Agencies to consider the evidence of the links between adverse childhood experiences, family violence and youth offending and put in place strategies to mitigate the risk.
All Agencies
Gloucester — recommendation 3
Probation services to ensure that Offender Managers are aware of the importance of exploring loss issues with service users when they do not have access to their children. This will need to be part of the Sentence planning process and clearly recorded.
BGSW CRC
Gloucester — recommendation 1
Probation services to continue working with domestic abuse perpetrators to get immediate starts on the Building Better Relationships Programme, or to identity where this intervention may not be suitable for an individual, so that the court can be informed of this and an alternative sentence imposed.
BGSW CRC
Portsmouth — recommendation 5
Domestic abuse training for primary care, with a focus on professional curiosity, routine enquiry, indicators of abuse and thinking family.
Hampshire and Isle of Wight Integrated …
NHS Hampshire and Isle …
Portsmouth — recommendation 1
There is an apparent lack of public understanding on the course of action to take if a third-party, witnesses or hears an incidence of domestic abuse occurring. This should be addressed with a Portsmouth wide campaign involving family, friends and communities to raise public awareness on what to do if …
Safer Portsmouth Partnership | Stop Domestic …
Kent — recommendation 15
The DASVEG to review and consider the implementation of the J9 project or to liaise with Advocacy After Fatal Domestic Abuse (AAFDA) and Wearside Women in Need (WWIN) who are currently working on a new initiative with the aim of enabling family, friends and communities to better support the people …
Kent and Medway Domestic Abuse and …
Kent — recommendation 1a
Public Health Suicide Prevention Programme to develop and distribute briefing materials, in a variety of formats, highlighting the link between domestic abuse and suicide that can be used to raise awareness amongst agencies and professionals. To highlight the usage of the DA website as a means to promote training and …
Kent and Medway Suicide Prevention Panel …
Doncaster — recommendation 1
That the Safer Stronger Doncaster Partnership conducts a domestic abuse campaign highlighting the different aspects of domestic abuse – including financial abuse, and referral pathways.
Safer Stronger Doncaster Partnership
Cheshire West and Chester — recommendation 3
Statutory partners to provide reassurance to the CSP that where appropriate and possible agencies should signpost relatives of those who misuse drugs and or alcohol to appropriate support, for example Alanon.
Cheshire West and Chester Community Safety …
Derby — recommendation 3
The Derbyshire and Derby Safeguarding Children Partnership, after the re-promotion of the Pre-Birth Protocol through the briefing issued May 2020, should provide assurance and data that pre-birth assessments are being completed when risks are identified to improve outcomes for pregnant women, unborn children and their wider families.
Derbyshire and Derby Safeguarding Children Partnership
Ashfield — recommendation 5.4
Whilst it is acknowledged that there is much work done to raise awareness, it is recommended that the partnership considers more innovative ways of getting the messages to young women, such as the victim, who are not having contact with agencies.
Ashfield Community Partnership
Swindon — recommendation 7
Develop Policy to increase opportunities for disclosure of Domestic Abuse Ratify and launch Trust-Wide DA Policy
Great Western Hospital NHS Foundation Trust
Great Western Hospitals NHS …
Swindon — recommendation 6
Review and amend processes to increase opportunities for disclosure of Domestic Abuse (DA)
Great Western Hospital NHS Foundation Trust
Great Western Hospitals NHS …
Swindon — recommendation 5
Review and amend processes to increase opportunities for disclosure of Domestic Abuse (DA)
Great Western Hospital NHS Foundation Trust
Great Western Hospitals NHS …
Swindon — recommendation 3
The national association of residential landlords (RLA) will promulgate domestic abuse awareness to members and will place a domestic abuse policy on national website
Residential Landlords’ Association | Swindon Women’s …
Swindon — recommendation 1
There is an apparent lack of public understanding on what course of action to take if a third party witnesses or hears an incidence of domestic abuse occurring. This should be addressed with a Swindon-wide campaign involving family, friends and communities to raise public awareness on what to do if …
Swindon CSP | Partnership agencies | …
Oxford — recommendation 3
To disseminate guidance for settings/schools, colleges and professionals and parents on identifying and supporting children and young people with social, emotional and mental health difficulties as a graduated response to special educational needs, in line with the Children and Families Act 2014.
Schools and Special Educational Needs
Oxford — recommendation 5
The OSCB to seek assurance that the programme provided by schools in Oxfordshire covers healthy relationships in the context of domestic abuse.
Oxfordshire Safeguarding Children Board
Powys — recommendation 3
All publicity campaigns in Powys will specifically highlight issues of coercion and control.
Commissioning Manager (Violence Against Women, Domestic …
Powys — recommendation 2
To support and evaluate the community based ‘Ask Me’ pilot scheme in selected communities in Powys.
Welsh Women’s Aid | Powys County …
Powys County Council
Powys — recommendation 1
Promote public awareness of domestic violence issues and services across Powys and in particular the Live Fear Free Helpline.
Commissioning Manager (Violence Against Women, Domestic …
Police Services
Hillingdon — recommendation 4.5.7
SHP to review the effectiveness of the information available to the public about the appropriate action to take if they have concerns about the risk of domestic violence against a person, to enable the police and other agencies to intervene positively.
Safer Hillingdon Partnership (SHP)
Hillingdon — recommendation 4.5.4
SHP to undertake a needs assessment and review of existing domestic abuse specialist support services (including the management of IDVA), and develop a comprehensive commissioning strategy that meets the needs of both victims and perpetrators and includes a focus on prevention and early intervention.
Safer Hillingdon Partnership (SHP)
Hillingdon — recommendation 4.5.2
SHP to ensure that all partner agencies conduct an internal review of their domestic violence/abuse policies and procedures in relation to how they identify, risk assess, refer and respond appropriately to victims, particularly those who don’t engage and/or are subject to coercive control, and make changes as appropriate. This must …
Safer Hillingdon Partnership (SHP)
South Tyneside — recommendation AP4
Raise public awareness of how to identify and seek appropriate help for mental ill health
NTW | South Tyneside Council - …
Cumbria, Northumberland, Tyne and …
South Tyneside — recommendation AP3
To ensure that wider social factors are taken into consideration in Early Help assessments.
South Tyneside Council - Early Help
South Tyneside — recommendation AP2
To ensure that staff who come into contact with potential victims of domestic abuse are effectively trained.
STNHSFT
South Tyneside — recommendation AP1
To ensure Routine & Selective Enquiry are embedded in practice within STNHSFT (continued action from DHR#1)
STNHSFT
South Tyneside — recommendation 18.2.3
Dissemination of learning from the IMR across the Early Help Partnership with a view to: a) Strengthening communication between all professionals with the Early Help Plan; b) Ensuring the engagement with families as a whole unit (as appropriate) in the work being undertaken; and c) Providing effective challenge where family …
South Tyneside Council: Early Years Service
South Tyneside — recommendation 18.2.3
Early Help and Advice Teams to review their systems for recording information and advice calls and referrals as appropriate.
South Tyneside Council: Early Years Service
Lancaster — recommendation 13.
All women receiving maternity care from ELHT are asked routine enquiry at least once during their maternity care episode
East Lancashire Hospitals NHS Trust
East Lancashire Hospitals NHS …
Lancaster — recommendation 11.
Clinicians should be aware of the increased risk of DA following separation particularly in the initial post-separation period
East Lancashire Clinical Commissioning Group
Lancaster — recommendation 9.
The practice should incorporate routine screening questions for domestic abuse into its new patient checks.
East Lancashire Clinical Commissioning Group
Lancaster — recommendation 7.
NICE guideline PH50 recommends screening for DA both ante and postnatally as several studies have shown there is increased risk of domestic abuse at those times. The practice should incorporate DA screening questions into any ante or postnatal protocols.
East Lancashire Clinical Commissioning Group
CJINI inspection reports(11)
Northern Ireland Alternatives
Restorative Justice, Other Agencies and Organisations
Feb 2010
Community Restorative Justice Ireland
Restorative Justice, Other Agencies and Organisations
Aug 2011
Early Youth Interventions
Youth Justice and Intervention, Children and Young People
Jul 2012
Youth Interventions: An Inspection of the Youth Justice Agency’s Community Interventions
Youth Justice and Intervention, Children and Young People
Sep 2024
An inspection of the Probation Board for Northern Ireland Community Service Scheme
Probation Board for Northern Ireland (PBNI), Probation and …
Mar 2010
The use of Youth Diversion in the criminal justice system
Youth Justice and Intervention, Children and Young People
Jul 2011
Anti-Social Behaviour an inspection of the criminal justice system’s approach to addressing anti-social behaviour in Northern Ireland
Policing, Policing and the Community, Crime
Oct 2012
An inspection of the criminal justice system’s approach to addressing anti-social behaviour in Northern Ireland
Crime, Other Crimes
Oct 2012
The effectiveness of Youth Conferencing – A Follow-Up Review
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Apr 2019
An Inspection of the Voluntary Community and Social Enterprise Sector’s Engagement with the Criminal Justice System in Northern Ireland
Voluntary and Community Sector, The Criminal Justice System
May 2019
Policing and Community Safety Partnerships
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