Public Infrastructure Physical Hazards
Dangerous conditions of public infrastructure (e.g., canal bridge steps) and poor lighting, creating significant safety hazards.
Source spread
Where this theme appears
This theme appears across 24 independent accountability sources, so the source mix matters as much as the headline total.
158 inquiry recs
204 PFD reports
307 committee recs
8 HSSIB recs
256 CQC actions
1 ICIBI rec
2 PPO recs
2 IOPC recs
1 NAO rec
111 IMB recs
2 IMB reports
31 Scottish FAIs
1 detention investigation rec
1 DHR rec
2 PHSO decisions
309 LGO/SPSO decisions
2 CJINI reports
1 DSA service inquiry
6 CQC enforcement actions
1 EHRC compliance action
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(158)— showing 50 strongest matches
54 — Design of overhead line structures
Recommendation: Consideration should be given to modification to the design of OHL structures to improve their response to accidents, if achievable without detriment to their primary role (para 11.16).
Unknown
26 — In-service wheel diameter difference limit
Recommendation: The consequences of allowing the development, on a given axle, of an in-service wheel diameter difference which is considerably in excess of the limit imposed after reprofiling should be examined and, if appropriate, an in-service limit should be introduced.
Unknown
25 — Body-to-bogie connection failure modes
Recommendation: Standards that prescribe strength requirements for body-to-bogie connections in vehicles should require that the potential modes of failure are determined at the design stage, and that action be taken to ensure that the integrity of the vehicle body structure is …
Unknown
24 — Secure OLE balance weights
Recommendation: Consideration should be given to the reasonable practicability of securing OLE balance weights to reduce the risk of separation if they are struck during an accident.
Unknown
23 — Steel fencing in underbridge gaps
Recommendation: Consideration should be given to the use in future underbridge designs of steel fence construction rather than brickwork for filling gaps of the type found between the separate bridges at the Potters Bar site.
Unknown
14 — Minimum flangeway gap with wide gauge
Recommendation: Taking into account the outcome of the action recommended in 13 above, consideration should be given to increasing the minimum allowable flangeway gap between open switch rails and stock rails in situations where wide gauge is found in points and …
Unknown
13 — Flangeway clearance requirements
Recommendation: Consideration should be given to revising the requirements for setting flangeway clearances in points in order to avoid contact between the flangebacks of wheels and open switch rails over the permissible ranges of wheelset and track geometry. The revision should …
Unknown
6 — Crank pivot design and inspection
Recommendation: Consideration should be given to whether the design of crank pivots should be improved, and/or whether the inspection regime should be improved to allow earlier detection of failures of Spirol pins.
Unknown
89 — Standards for standby vessels
Recommendation: It should be required by regulations that each standby vessel should comply with the following standards:- (i) It should be highly manoeuvrable and able to maintain its position; (ii) It should provide full visibility of the water-line in all directions …
Unknown
87 — Combined survival suit and life-jacket
Recommendation: Work should be carried out with the objective of combining the functions of a survival suit and a life-jacket in one garment (para 20.32).
Unknown
84 — Escape chutes and collapsible stairways
Recommendation: The regulatory body should work with the industry to determine the practicability and safety of escape chutes and collapsible stairways (para 20.30).
Unknown
83 — Variety of means of descent to the sea
Recommendation: A variety of means of descent to the sea should be provided on all installations. In accordance with recommendation 75 the types, numbers and locations of facilities for this purpose should be specified in the evacuation, escape and rescue analysis; …
Unknown
82 — Life rafts
Recommendation: It should be required by regulation that each installation should be provided with life rafts having in the aggregate sufficient capacity to accommodate safely on board at least the number of persons on board the installation; along with suitable ropes …
Unknown
81 — Free-fall TEMPSC
Recommendation: Reg 5 of the Life-Saving Appliances Regulations should be amended or replaced so as to enable free-fall TEMPSC to be installed on new and existing installations. It should remain for the operator to justify its choice of TEMPSC as being …
Unknown
80 — Launching TEMPSC clear of the installation
Recommendation: The regulatory body should work with the industry to develop equipment and methods to enable TEMPSC to be launched clear of the installation including where, as on existing installations, they are oriented so as to point along the side of …
Unknown
79 — Orientation of davit-launched TEMPSC
Recommendation: On new installations where the provision of davit-launched TEMPSC is acceptable to the regulatory body they should be oriented so as to point away from the installation (para 20.24).
Unknown
78 — TEMPSC capacity
Recommendation: The requirement by regulation that each installation should be provided with TEMPSC having in the aggregate sufficient capacity to accommodate safely on board 150% of the number of persons on the installation should be maintained (para 20.16). Such provision should …
Unknown
15 — Fuel flasks to continue by rail
Recommendation: Fuel flasks should, as far as possible, continue to be delivered to Windscale by rail, but this is not a matter appropriate to planning conditions (paras 14.28 and 14.45).
Unknown
2 — Krypton 85 removal plant development
Recommendation: BNFL should devote effort to the development of plant for the safe removal and retention of krypton 85 and, if development proves successful, should incorporate it in the proposed plant (para 10.52).
Unknown
RONA-44 — Code of Practice for large concrete panel construction
Recommendation: A Code of Practice applicable specifically to large concrete panel construction should be prepared and published as a matter of urgency (paragraph 210).
Unknown
RONA-43 — Building Regulations to cover progressive collapse
Recommendation: The Building Regulations should include provisions dealing with progressive collapse (paragraph 208).
Unknown
47 — Internal doors that open easily in a crash
Recommendation: The design of coaches should be such that internal doors can be easily opened in a crash situation, in darkness and irrespective of the attitude of the vehicle; and that hammers intended for breaking windows can be easily located in …
Unknown
35 — Regular checks on signal alignment and sighting
Recommendation: Railtrack should ensure that checks on alignment and sighting of signals are made at least annually, and at a greater frequency to be determined on the basis of errors found (paras 3.16, 16.14).
Unknown
34 — Check signal alignment and sighting at commissioning
Recommendation: Railtrack should ensure that the alignment and sighting of signals is confirmed at the time of commissioning, both from the signal and from the track, and appropriate records made, including photographs (paras 3.16, 16.14).
Unknown
20 — Patrolman training on stretcher bars
Recommendation: Consideration should be given to enhancing the competence of CE patrolmen, by the provision of additional training, to enable them to recognise and report emerging problems such as loose nuts and off-centre threads on adjustable stretcher bars, during basic visual …
Unknown
9 — Check flangeway gaps with supplementary drives
Recommendation: A requirement should be introduced for flangeway gaps and supplementary drive settings on points to be checked together at defined intervals as part of maintenance.
Unknown
7 — Quality control of insulating bushes
Recommendation: Requirements for the quality control of insulating bushes procured for use on adjustable stretcher bars should be reviewed and enhanced where necessary.
Unknown
3 — Managerial controls for stretcher bar risks
Recommendation: A system of managerial controls to mitigate the risks associated with adjustable stretcher bar assemblies should be developed and implemented.
Unknown
2 — Stretcher bar training programme
Recommendation: A training programme based on the guidance contained in Network Rail Company Code of Practice RT/E/C/10179, The Set Up and Maintenance of Adjustable Stretcher Bars - A Good Practice Guide should be developed. All signal installation and maintenance staff, their …
Unknown
88 — Quality of standby vessels
Recommendation: Changes in the regulations and the code for the assessment of standby vessels should be aimed at an improvement in the quality of standby vessels, introducing basic standards for existing vessels and higher specifications for new vessels (para 20.41).
Unknown
86 — Survival suits and life-jackets
Recommendation: The use of small transmitters or detectors on life-jackets in order to assist in the finding of personnel in the dark should be considered. Luminescent strips should be of a colour other than orange (paras 20.33-34).
Unknown
85 — Personal survival equipment for each person
Recommendation: Each individual on board an installation should be provided with:- (i) a personal survival (or immersion) suit; (ii) a life-jacket; (iii) a smoke hood of a simple filter type to exclude smoke and provide protection for at least 10 minutes …
Unknown
72 — Shutdown in emergency on connected installation
Recommendation: Operators should be required by regulation to institute and review regularly a procedure for shutting down production on an installation in the event of an emergency on another installation which is connected to the first by a hydrocarbon pipeline where …
Unknown
69 — Immediate review of emergency systems
Recommendation: The regulatory body should ask operators which have not already done so to review forthwith the ability of emergency systems to withstand severe accident conditions (para 19.191).
Unknown
68 — Studies on emergency system vulnerability
Recommendation: Studies should be done to determine the vulnerability of emergency systems to severe accident conditions and to enhance their ability to survive such conditions (para 19.190).
Unknown
64 — Survivability of emergency systems
Recommendation: The regulations and related guidance notes should promote an approach to emergency systems:- (i) which provides to a high degree the ability of these systems to survive severe accident conditions (paras 19.188-189); and (ii) which applies to communications systems the …
Unknown
62 — Facilities for control of emergencies
Recommendation: It should be required by regulation that there should be available within the TSR certain minimum specified facilities for the monitoring and control of an emergency under hostile outside conditions (paras 19.178 and 19.182). These facilities should be in the …
Unknown
61 — Studies on breathable air in the TSR
Recommendation: Studies should be carried out with the objective of assisting designers in predicting the breathability of air in a TSR where its external fire wall is subjected to a severe hydrocarbon fire (para 19.163).
Unknown
56 — Protection of accommodation
Recommendation: The regulations and the related guidance notes should promote an approach to protection of the accommodation:- (i) in which external fire protection is provided both to prevent breach of the accommodation and to maintain breathable air within it (para 19.170); …
Unknown
50 — Approach to fire and explosion protection
Recommendation: The regulations and related guidance notes should promote an approach to fire and explosion protection:- (i) which is integrated as between - — active and passive fire protection — different forms of passive fire protection, such as fire insulation and …
Unknown
48 — Vulnerability of emergency shutdown valves
Recommendation: Studies should be done to determine the vulnerability of ESVs to severe accident conditions and to enhance their ability to survive such conditions (para 19.43).
Unknown
46 — Studies on riser protection and SSIVs
Recommendation: Studies should be carried out with the following objectives:- (i) To achieve effective passive fire protection of risers without aggravating corrosion (para 19.22). (ii) To improve the reliability and reduce the cost of SSIVs so that it is more often …
Unknown
45 — Studies on inventory and pipeline connections
Recommendation: Studies should be carried out with the following objectives:- (i) To explore the feasibility of dumping in an emergency large oil inventories, such as those in the separators, in a safe and environmentally acceptable manner, so as to minimise the …
Unknown
7 — Safety Case specification of TSR and escape
Recommendation: In connection with the above the Safety Case should specify the following:- In respect of the TSR- — its function — the conditions which constitute its integrity — the conditions for integrity of its supporting structure — the events in …
Unknown
6 — Temporary Safe Refuge as accommodation
Recommendation: The TSR should normally be the accommodation (paras 19.156 and 19.161). In the case of existing installations any requirement for the upgrading of the accommodation, escape routes and embarkation points should be determined on the basis of the Safety Case …
Unknown
RONA-36 — Owners of tall non-system-built blocks to check wind loads
Recommendation: Owners of tall post-war blocks (say over 100 feet high) that are not system-built should inquire into the wind loads for which the blocks were designed and seek professional advice as to the adequacy of their buildings to withstand the …
Unknown
RONA-33 — Use recent wind research pending the new loading Code
Recommendation: Until the new wind loading Code is produced, designers should have regard to the results of recent research into the frequency and duration of high wind speeds, when calculating the wind loadings for which the blocks are to be designed …
Unknown
RONA-32 — New blocks to be designed against progressive collapse
Recommendation: Designers of new blocks must design the building so that it is not susceptible to progressive collapse, paying particular attention to introducing continuity at the joints and so disposing the load-bearing walls that alternative paths are provided in the event …
Unknown
87 — Faster earthing and isolation of traction current
Recommendation: Consideration should be given to means of speeding up the process of earthing and isolation of traction current following an accident on an electrified section of line (para 2.15).
Unknown
51 — Crumple zones in passenger carriages
Recommendation: No recommendation is made concerning crumple zones in passenger carriages, save that the matter should be given attention by the Ladbroke Grove Inquiry (para 11.4).
Unknown
Prevention of Future Deaths reports(204)— showing 50 strongest matches
Matthew Thomas Hamilton
Concerns: The absence of a barrier at the end of the footpath, combined with a narrow pavement and restricted visibility from tall fencing and shrubbery, creates a hazard for children emerging onto the road.
Overdue
Sadie Ann Jane McGrady
Concerns: The coroner identifies concerns that substandard structural repairs to Category D insurance write-off vehicles can increase injury severity in collisions. There are insufficient independent checks on such repairs before vehicles return to the road, and the MOT process may not detect compromised structural integrity.
Response (Association of British Insurers): • The Association of British Insurers (ABI) provided a copy of the Code of Practice for the Disposal of Motor Vehicle Salvage, which was developed in 1996 in collaboration with … (AI summary)
Response (Department for Transport): • The Department for Transport is currently reviewing the Vehicle Identity Check (VIC) Scheme, analysing ideas put forward during a consultation. • The Department stated that should Ministers decide to … (AI summary)
Overdue
Joseph Drew Whiteside
Concerns: The coroner raises concerns following several deaths of intoxicated young men falling into the River Trent, identifying a need for a review of safety measures. The report suggests considering further actions such as fencing or warning signs at main river access points.
Response (East Staffordshire Borough Council1): • The Council appointed the Royal Society for the Prevention of Accidents (RoSPA) to conduct inland water safety reviews. • RoSPA completed the review in October and November 2013, identifying … (AI summary)
Responded
Dr Edward Slaney
Concerns: The coroner notes a lack of appropriate criteria for assessing the wind effects of tall buildings on highway users' safety. There is also a need for guidance to planning authorities to consider these wind effects on all road users.
Overdue
Elizabeth Turnbull
Concerns: The coroner identified concerns regarding the design of thumbwheel controls, noting their layout allowed for inadvertent release of locking pins and the absence of dual controls for this function.
Overdue
Sidney Harvey
Concerns: The coroner raised concerns about the presence of non-safety glass doors in rented properties where elderly people or children are occupants, and the lack of a system for replacing or making these doors safe.
Overdue
Kathleen Border
Concerns: Concerns were raised about a delivery vehicle reversing from a car park rather than using a designated delivery area, and that signage for parking areas was not prominent or clear.
Response (Hanover): • An additional sign was installed to alert drivers to pedestrian presence and to exercise caution when reversing. • Residents and visitors will be reminded via the estate newsletter to … (AI summary)
Responded
Ryan Pettengell
Concerns: The coroner noted that six months after safety recommendations were made for a site with a previous drowning, no action had been taken. Public access continues despite closure, and signage prohibiting swimming is either absent or damaged.
Overdue
Doris Taylor
Concerns: The coroner noted the need for staff training on what constitutes a reportable incident and for managers to be aware of their duty to report. Concerns were also raised regarding the safety and appropriate strength of door-closers to prevent injury.
Overdue
Muriel Dawson
Concerns: The coroner raised concerns about the design of Optare "hopper" buses, where the lack of seat restraints contributed to an elderly passenger's fatal injury. The report suggests the vehicle's type-approval process gives insufficient weight to serious injury risks.
Response (Department for Transport): • The Department for Transport stated it would bring the Coroner's concerns to the attention of bus manufacturers through the Society of Motor Manufacturers and Traders (SMMT) technical group. • … (AI summary)
Overdue
Sidney Martin
Concerns: The coroner noted that the steps from the canal bridge leading to Gas Street in Skipton are in a dangerous condition, further compounded by poor lighting in the bridge area.
Response (Canal River Trust): • The Trust undertook an investigation visit to the bridge. • The Trust's Health and Safety Advisor and the respondent separately inspected the steps. • The Trust confirmed the step … (AI summary)
Overdue
Sopefoluwa Peters
Concerns: Concerns were raised about steep, poorly illuminated steps lacking a handrail, making them difficult to negotiate. Additionally, a low riverside wall opposite the steps was noted as an insufficient safety barrier.
Response (Durham County Council): • The Council stated it would install a timber barrier in the riverside footpath adjacent to the wall opposite the Drury Lane exit, anticipated within two weeks. • The County … (AI summary)
Responded
Ernest Harper
Concerns: Concerns were raised about a gap between a safety barrier and the back of a vehicle that allowed a fall. The report also notes that passenger health and mobility risk assessments relied solely on voluntary information rather than a formal process.
Response (Bedford Borough Council): • Devices were retro-fitted to the doors of all Ford Transit vehicles to block gaps between the vehicle and handrail. • A redesigned Client Transport Referral form was devised to … (AI summary)
Responded
Mitchell Clifton
Concerns: The coroner suggested improvements to the layout of the Co-operative car park access way, noting it is regularly used by pedestrians and vehicles. Possible enhancements included tactile paving, extending road markings, or a central island.
Response (Staffordshire County Council): • The Council reported that the Co-operative had introduced road humps, lane markings, a central hatched area, and a marked pedestrian route at the car park entrance. • The Council … (AI summary)
Response (Department for Transport): • The Department for Transport stated it had considered national road casualty data for light commercial vehicles. • The Department for Transport indicated it was not convinced that changes to … (AI summary)
Responded
Harold Henshall
Concerns: The coroner identified inadequate street lighting on Church Street, Leek, increasing risk for pedestrians, particularly elderly church users. Crossing facilities near St Edwards Church were also insufficient, exacerbated by the road's gradient and driver visibility challenges.
Overdue
Sophie Allen
Concerns: The coroner raised concerns about the ongoing danger of looped blind cords to young children, emphasising the risk posed by millions of blinds already installed in homes. There is a need for extended public awareness campaigns for parents, grandparents, and carers.
Response: • The Department for Business, Innovation and Skills supports the British Blind and Shutters Association and RoSPA's "Make it Safe Campaign" through widespread distribution of 1.6 million leaflets and extensive … (AI summary)
Responded
Charles Hardiman
Concerns: The coroner noted concerns regarding a wind tunnel effect, created by open front and back doors of the Public House, which caused the back door to move suddenly and forcibly, resulting in an accident.
Overdue
Ahmad Khan
Concerns: The coroner noted the perimeter wall's low height (3 feet) and the presence of a crash-protective barrier acting as a step, making it easy for individuals to gain access to the top of the wall, creating a dangerous situation.
Responded
Gary Daltry
Concerns: The coroner noted an unmitigated tripping hazard at the location, which could lead to further falls and injuries, risking future deaths.
Response (Denbigshire County Council): • The council conducted a record search for incident data and performed a risk level calculation. • A site visit was carried out, leading to risk assessments and recommendations for … (AI summary)
Responded
Muriel Naylor
Concerns: The coroner noted a significant risk for vulnerable bus passengers due to the lack of restraints or screen barriers for priority seating, which is not mandated by current regulations. Fitting seat belts to these seats would require significant modification and testing.
Response (Department for Transport): • The Department for Transport made enquiries with the Driver and Vehicle Licensing Agency regarding the vehicle's certification and roadworthiness. • The Department for Transport brought the issue to the … (AI summary)
Overdue
Michael Harrison
Concerns: The coroner raised concerns regarding insufficient measures to treat ice that had formed in the car park.
Overdue
Lynn Gormly
Concerns: The low-level design of Queensgate Car Parks and other city centre car park walls does not effectively prevent individuals from jumping. This design contrasts with modern car parks and poses a risk to both individuals and pedestrians below.
Response (Invesco): • A feasibility study identified a web-net system as the preferred solution for infilling and over-cladding car park openings. • Planning approval for the web-net system is to be sought … (AI summary)
Overdue
William France
Concerns: The coroner raised concerns regarding obstructed visibility for drivers approaching the level crossing due to a rise, barrier controls, and the road angle. There were also concerns about the level crossing telephone being positioned 8 metres beyond the pedestrian stop line.
Overdue
Aaron Plowman
Concerns: The coroner notes that access to the roofs of commercial units under railway arches has not been blocked, specifically from the Lycamobile kiosk and Sonny Kebab and Chicken shop.
Overdue
Jerome Gonnet
Concerns: The coroner noted a lack of clear advance signage indicating a slip road is 'no entry' and that temporary signs at the exit are prone to being knocked over. These issues have led to repeated instances of drivers mistakenly using the slip road.
Response (A one): • A-one+ confirmed that permanent illuminated 'No entry' signs were in place and that supplementary signs had been installed. • A-one+ stated that supplementary signs are regularly inspected and any … (AI summary)
Overdue
Jake Johnson
Concerns: The coroner noted open access to the M56 motorway via steps, damaged boundary fencing nearby, and an absence of warning signs for the public, particularly given a children's play area in the vicinity.
Overdue
Victoria Rhodes
Concerns: The coroner raised concerns regarding the 70 mph speed limit on the grid roads in Milton Keynes and pedestrian access to these fast roads, recommending a review of the speed limit.
Response (Milton Keynes Hospital): • Transport and Highways officers met with the Police in May to consider appropriate actions. • Cabinet endorsed a comprehensive road safety review in July, with a report due by … (AI summary)
Responded
Gavin Bradley, Mark Thorpe and Darren Thorpe
Concerns: The coroner questioned the feasibility of amending Riding Mill weir to incorporate a dedicated channel for canoes and kayaks, and constructing a safe upstream landing area with warnings for river exit during heavy flows.
Overdue
Kai Lambe
Concerns: The coroner raised concerns about the extreme risks posed by the weir and salmon chute at the location, noting insufficient warning signage. The report asks for improved safety measures and clarification of responsibility for the site.
Overdue
Wade Patel
Concerns: The coroner identified that old glass in properties often does not meet current safety regulations, and landlords have no legal requirement to specifically check its safety. This means replacement typically occurs only during refurbishment or after breakage, which resulted in a death.
Response (Department for Communities Local Government): • The Department for Communities Local Government stated it has no plans to change the application of Building Regulations to retrospectively apply current standards to existing buildings. • The Department … (AI summary)
Responded
Stephen Simpson
Concerns: The building design lacks an entrance lobby to arrest falls, increasing the risk of serious injury from impact with the external door. The communal stairs are also made of smooth concrete without a non-slip surface.
Overdue
Myra Goldman
Concerns: The coroner raised concerns that the current British Standard for steel palisade fences does not adequately address safe gate hinge design, specifically the practice of inverting an upper hinge pin which concentrates weight. An expert recommended the standard be changed to promote safer hinge arrangements.
Response (BSI): • The committee responsible for BS 1722-12:2006 accepted a proposal to review the Standard. • The reviewed Standard is expected to be published in 2016. • The coroner's letter was … (AI summary)
Overdue
Mark Burdett
Concerns: The coroner identified the lack of a sign warning motorists of a concealed entrance, particularly for traffic approaching from the Coleshill direction.
Overdue
Hilary Moock and Janice Taylor
Concerns: The A285 is an ancient, high-risk rural road that does not meet modern design standards. A specific entrance on the road is unlit, has limited sightlines, and an unmade surface, leading drivers to slow and risk collisions.
Response (West Sussex Council): • West Sussex County Council stated that the specific location of the incident did not meet its criteria for investigating collision cluster sites for remedial measures. • The Council concluded … (AI summary)
Responded
Isaac Nash
Concerns: The coroner noted that the river estuary part of Aberffraw beach can be subject to very strong currents, of which the public are unaware without local knowledge. The report suggests erecting signs to warn the public of this potential danger.
Response (Response Isle of Anglesey County Council): • The Council held six meetings with the local community, including the Aberffraw Community Council. • A risk assessment was undertaken by the Council's Maritime Team, and arrangements are in … (AI summary)
Responded
John Darling
Concerns: The coroner noted an unguarded cafe platform edge with a metre drop, posing a fall risk, particularly for children or those in buggies, a risk exacerbated by an incline. The planning department had not required a safety barrier.
Overdue
Jordan Roberts
Concerns: The coroner noted that existing warning signs about a particularly deep pool and strong currents in the River Wear were inadequate and not visible from both riverbanks, raising concerns about public awareness of the dangers.
Response (Durham County Council): • Durham County Council undertook a safety assessment of the northern river bank, involving a Royal Society for the Prevention of Accidents (ROSPA) consultant. • Larger, improved hazard warning signs … (AI summary)
Overdue
Robbie Williamson
Concerns: The coroner identified the presence of exposed raised pipework, accessible to the public and potentially attached to bridges, which falls under the organisation's responsibility.
Overdue
Elliott Bignall
Concerns: The coroner noted poor lighting and inadequate signage at the Langmeads foot crossing. These issues increase the risk to pedestrians, especially those distracted by headphones or phones, who may not perceive approaching high-speed trains.
Overdue
Daniel Hodgin
Concerns: The coroner noted that a towpath gate, intended to be closed and locked when river levels reached 1.95 meters, was open despite higher water levels. There was no clear system for the Environment Agency to notify Shropshire Council of water levels, rendering the gate closure instruction ineffective.
Response (Environment Agency): • The Environment Agency spoke with Shropshire County Council to assist them in utilising the provided river level information. • A technical note was produced for the council to aid … (AI summary)
Response (Shropshire Council): • Shropshire Council engaged a software company to develop an automatic alert system for river levels, with the intention of sending SMS messages to key personnel for timely gate closure. … (AI summary)
Overdue
Paul Littlewood
Concerns: The coroner identified inadequate height of fixed barriers and fall protection at the gantry's access ladder, noting the absence of an intermediate crossbar and a toe-plate. Recommendations included safer barrier heights, self-closing mechanisms, and a falls arrest system.
Response (Freight Transport Association): • The Freight Transport Association stated it would continue to provide guidance to its members on assessing and managing risk. • This guidance includes its 'Preventing Falls from Vehicles' publication, … (AI summary)
Overdue
Fred Hudson
Concerns: The coroner noted that a disused railway bridge (ABO8) is easily accessible to the public, including children, with no measures in place to prevent access despite its location next to a main road and frequent visits.
Overdue
Steven Bottomley
Concerns: The coroner noted the window was not fitted with a safety device. Concerns were raised regarding the need to review its safety and take remedial action for similar windows across properties to comply with building regulations.
Pending
Matthew Hoare
Concerns: The coroner noted the lack of effective security equipment preventing access to the station and tracks after hours, and the ease with which Mr Hoare could access the area by climbing through widely spaced tape.
Response (Network Rail): • Roller shutters at the station entrance were reinstated and are now locked during non-operational hours. • Anti-trespass grids were installed at the Denmark Hill end of the platforms. • … (AI summary)
Responded
Colette Hughes
Concerns: The coroner notes concerns that an easily accessible wall, where previous deaths have occurred, poses a risk of further deaths and danger to visitors who might use it as a seating area, particularly after consuming drink or drugs.
Response (Hammerson PLC): • Hammerson plc stated it would introduce hostile planting to restrict access to parapet walls on Level 3. • The company stated it would install hostile planting on lower level … (AI summary)
Responded
Adam Connelly
Concerns: The coroner noted that the height of the walls of the steps accessing footbridge 57 allowed easy access to the railway tracks, creating a risk of future fatalities at this location.
Response (Network Rail): • Network Rail stated it would install shorter palisade pales to raise the overall height of the lower flight parapet to a minimum of 2m. • Network Rail stated it … (AI summary)
Overdue
Ashley Matthews
Concerns: The coroner noted insecure fencing allowed access to the site, with some perimeter fencing secured by cable ties, and that family members could access the site unchallenged after the death. Additionally, there were no warning signs on Bridge 26 about the dangers of high voltage cabling.
Response (British Transport Police): • Palisade fencing has been extended to prevent access to the over bridge. • Warning signs for electrocution have been placed on the over bridge. • Network Rail is investigating … (AI summary)
Responded
Ben Hiscox
Concerns: The distance between the touchline and the clubhouse was less than FA recommended guidelines, potentially putting players at risk, and the referee did not take action regarding this on the day.
Overdue
Joyce Plested
Concerns: The coroner noted safety concerns regarding a zebra crossing's proximity to a busy mini roundabout and store entrance. An expert suggested relocating the crossing further away and installing pedestrian barriers to enhance safety.
Overdue
Alexander Hadley
Concerns: The coroner noted people were unaware of dangerous currents below a waterfall, creating a risk of future deaths. A warning sign is needed to inform people of the waterfall pool's hazardous characteristics.
Response: • Gwynedd Council stated it had ordered and received safety warning signs. • The council confirmed the signs would be placed near the waterfall pool to warn visitors of dangerous … (AI summary)
Responded
Select committee recommendations(307)— showing 50 strongest matches
#14 —
Recommendation: The UK’s existing critical national infrastructure is vulnerable to a range of threats, from extreme weather to cyber-attacks. In expanding and renewing that infrastructure in response to a growing population and the net zero transition, the UK may be forced …
#12 —
Recommendation: Maritime infrastructure, together with the UK’s telecommunications and energy systems, underpin these supply chains. The events of recent years, notably Houthi attacks on commercial ships in the Red Sea, have demonstrated the continuing centrality of maritime security to the UK …
#46 —
Recommendation: Building new towns, connecting them to utilities and then populating them—but without ensuring that they have a sustainable supply of water and energy—would constitute a risk to national resilience. This would be irresponsible. Mr Colville alerted the Committee to the …
#45 —
Recommendation: There should not be competition between data centres and new towns. This reflects decades of underinvestment in critical utilities infrastructure, which has left us unable to effectively advance projects which would support economic growth and job creation. Utilities and resilience
#41 —
Recommendation: There is minimal spare capacity in the UK’s water supply, making it vulnerable to droughts and increases in demand. 63 Stuart Colville, Deputy Chief Executive of WaterUK, told the Committee that “in some parts of the country, headroom—spare water—is down …
#40 —
Recommendation: The construction of new towns will cause two challenges for the water industry: first, new homes and amenities will need to be connected to the mains water supply. Secondly, the wider national supply of water will need to meet the …
#36 —
Recommendation: New towns will require a constant supply of water, energy and digital connectivity for their new inhabitants. Unfortunately (and deeply regrettably) this presents a challenge for the Government, because of decades of poor planning and a lack of effective preparation …
#79 —
Recommendation: The UK Government’s proposed solution to this issue is the Integrated Plan for Water, which aims to “transform management of the whole water system, deliver a clean water environment for nature and people, and secure a plentiful supply of water”. …
Response attribution not verified
#70 —
Recommendation: Following the passage of the Levelling-up and Regeneration Bill, the Secretary of State should use their powers to ensure that all wastewater treatment works with capacity for a population of 250 are upgraded by the 2030 deadline.
Response attribution not verified
#199 —
Recommendation: Transit through the Northwest Passage is limited as ice coverage is more extensive than in the Northeast Passage and will continue to be so for the foreseeable future. Rising temperatures are increasing the number of icebergs calved from glaciers and …
Response attribution not verified
#178 —
Recommendation: A warming Arctic means that previously inaccessible maritime regions may open up to economic activity. We heard from several witnesses, however, that the region would nevertheless remain a challenging environment in which to operate. Consequently, a substantial increase in economic …
Response attribution not verified
#121 —
Recommendation: Close co-operation between the state and the private sector, which operates most subsea cables and pipelines, is key to deterring threats to critical infrastructure. The UK Government should establish partnerships for working with businesses to combat threats to critical infrastructure.
Response attribution not verified
#92 —
Recommendation: The Tony Blair Institute told us that state collaboration with major tech companies would be key for internet resilience in the Arctic and beyond. They recommended that the UK should support investment in alternative Arctic infrastructure. The UK could also …
Response attribution not verified
#90 —
Recommendation: Dr Willett told us that international collaboration was “critical” to respond to the threat of maritime sabotage and the “one thing that potential adversaries of the West do not have”. 109 Dr Willett also emphasised the importance of effective collaboration …
Response attribution not verified
#89 —
Recommendation: A range of measures can be taken to deter threats to critical infrastructure, depending on the type of asset used. Dr Kaushal highlighted that GUGI possessed a limited number of specialised assets able to operate at extreme depths. GUGI also …
Response attribution not verified
#88 —
Recommendation: On 18 May 2023, the UK and Norway agreed to develop a strategic partnership “to counter shared threats in the undersea domain” including threats to undersea infrastructure. Norway has already stepped up surveillance in the North Sea in response to …
Response attribution not verified
#87 —
Recommendation: The UK has invested in new capabilities to manage the threat to seabed infrastructure, including two new Multi-Role Ocean Surveillance (MROS) vessels operated by the Royal Fleet Auxiliary. These act as ‘motherships’ for a range of remotely operated and autonomous …
Response attribution not verified
#85 —
Recommendation: In addition, Dr Lee Willett noted that it can be difficult for states to respond rapidly to sub-threshold threats to critical infrastructure because cables and pipelines are typically privately owned and pass through many different legal jurisdictions. 100
Response attribution not verified
#81 —
Recommendation: Russian naval intelligence operates surface vessels that can be used for maritime sabotage, such as the Admiral Vladimirsky , which is officially classed as an oceanographic research vessel. Russian naval intelligence also uses Russian civilian ships, including fishing trawlers, to …
Response attribution not verified
#79 —
Recommendation: We were told by Dr Sidharth Kaushal, Research Fellow at the Royal United Services Institute, that within the Russian system, capabilities to conduct maritime sabotage sit within two organisational frameworks: the specialised Main Directorate of Deep-Sea Research (GUGI), and Russian …
Response attribution not verified
#78 —
Recommendation: There have been several unattributed incidences of damage to subsea infrastructure in the Arctic. In November 2021, the Lofoten-Vesterålen Ocean observatory, an underwater facility in northern Norway, was put out of service after more than 4.3km of its specially designed …
Response attribution not verified
#77 —
Recommendation: In 2017, then-Chief of Defence Staff Air Chief Marshal Sir Stuart (now Lord) Peach stated that Russia’s unconventional warfare capabilities were creating “a new risk to our prosperity and way of life” through the potential exploitation of “the vulnerability of …
Response attribution not verified
#76 —
Recommendation: Russia has developed a range of capabilities to sabotage and disrupt critical infrastructure, including undersea data cables in the Arctic and further afield. The specialised capabilities for deep-sea maritime sabotage are based on the Kola Peninsula in the Arctic. 89
Response attribution not verified
#75 —
Recommendation: Mathieu Boulègue told the Committee that the track record of recent sub-threshold incidents pointed to the fact that Russia is willing to take more risks and accept higher costs to put pressure on its neighbours, including in the European Arctic. …
Response attribution not verified
#63 —
Recommendation: This risk is compounded by the secrecy surrounding Russian activities in the Arctic and the Russian military’s willingness to engage in risky behaviour. Mathieu Boulègue told us: “If we look at the track record of Russian incidents in the past …
Response attribution not verified
#24 —
Recommendation: It is vital that regulation of shipping evolves to meet this challenge. As a leading maritime nation and the headquarters of the International Maritime Organisation, the UK should take a leading role in negotiating a new Polar Code. We call …
Response attribution not verified
#5 —
Recommendation: Close co-operation between the state and the private sector, which operates most subsea cables and pipelines, is key to deterring threats to critical infrastructure. The UK Government should establish partnerships for working with businesses to combat threats to critical infrastructure.
Gov response: Partially Agree 5. The UK government works with industry to combat threats to, and improve the resilience of, subsea infrastructure. This approach can be found in the recent agreement between the UK and Norway, announced …
Position Not Stated
#10 —
Recommendation: The UK EV market remains concentrated around high value cars (costing over £40,000) and SUVs. Unless the market changes to offer more affordable options to consumers, the Government’s objective of mass ownership of EVs will not be met. This must …
Response attribution not verified
#31 —
Recommendation: The Government should work with UKRI to commission research into the safety aspects of hydrogen storage and transportation, as well as the public acceptability of hydrogen transport and storage facilities.
Response attribution not verified
#30 —
Recommendation: Some uncertainties remain around some of the operating and safety parameters for hydrogen storage—for example, the potential for microbial production of hydrogen sulphide.
Response attribution not verified
#24 —
Recommendation: The Government needs to clarify the role it sees for hydrogen on the future energy system assuming its target is met, with an indication of how the clean hydrogen produced in 2030 will be used. It should bring forward the …
Response attribution not verified
#98 —
Recommendation: It was acknowledged amongst our witnesses that “there is a need for a mechanism to enable conversion of surplus retail space to other uses” 186 and RICS suggested that the conversion of long-vacant units into residential properties prevented buildings falling …
Response attribution not verified
#63 —
Recommendation: We heard that the issue of vacant properties and “neglectful” landlords could negatively impact the look and feel of a high street and could be a particular issue in disadvantaged areas. 124 Professor Tomaney told us that the issue of …
Response attribution not verified
#4 —
Recommendation: Recent events, including Russia’s invasion of Ukraine, the conflict involving Iran and the cost-of-living crisis, have increased the importance the public places on energy security including the physical security of energy 27 infrastructure which has been raised during the Committee’s …
#28 —
Recommendation: The Government should further explore cable protection zones for critical areas of cable concentration, policed by early warning indicators and heightened monitoring and response capabilities. This would require close co-operation with European partners, given the need to manage other maritime …
Response attribution not verified
#27 —
Recommendation: We support the Crown Estate’s ambitions to improve long-term spatial planning via the Marine Delivery Route Map. We urge those involved to ensure that plans prioritise a diversity of cable routes to avoid creating areas of concentrated targets. (Conclusion, Paragraph …
Response attribution not verified
#21 —
Recommendation: The Government should support the subsea cable industry in rolling out more extensive cable monitoring technology and should explore incentives to encourage such investment. This could include Government commitments to make better use of existing measures and data—for example more …
Response attribution not verified
#19 —
Recommendation: The Government should explore new options for taking a more robust approach to interdicting suspicious vessels—for example applying piracy provisions to cables that land in the UK or seeking a limited extension of domestic criminal law jurisdiction. It should commission …
Response attribution not verified
#8 —
Recommendation: The Government’s resilience concept focuses too much on ‘having lots of cables’. This pays insufficient attention to the network’s actual capacity to absorb shocks and does not account for onshore vulnerabilities and long-term trends towards a more brittle system. There …
Response attribution not verified
#7 —
Recommendation: To help mitigate risks around the clustering of high value targets, the Government should encourage subsea cable providers to connect to landing stations, terrestrial routes and data centres outside high-concentration points. (Recommendation, Paragraph 49)
Response attribution not verified
#6 —
Recommendation: The National Protective Security Authority (NPSA) and National Cyber Security Centre should require all UK landing stations to be target-hardened to sufficient levels to deter state-backed sabotage. They should require landing station operators to develop within 12 months an emergency …
Response attribution not verified
#5 —
Recommendation: Many cable landing stations are vulnerable to attack. The Government and operators must take the risk of state-backed sabotage seriously, including against targets in Europe. (Conclusion, Paragraph 47)
Response attribution not verified
#1 —
Recommendation: The UK’s strategic reliance on subsea cables will likely continue for the foreseeable future. The cable industry provides a commendable and commercially efficient repair service, which ensures good resilience against moderate damage. We do not believe there is an imminent …
Response attribution not verified
#5 —
Recommendation: The Department is placing unrealistic expectations on how soldiers operate Ajax vehicles safely when it has still not resolved the underlying noise and vibration issues. In November 2025 Exercise TITAN STORM was stopped when 33 soldiers reported symptoms from noise …
Response attribution not verified
#9 —
Recommendation: Lack of investment has also resulted in severe maintenance backlogs within the prison estate. As at April 2019, HMPPS had around 63,200 outstanding maintenance jobs. HMPPS also estimated that it would cost £916 million to address its backlog of major …
Response attribution not verified
#18 —
Recommendation: Leaseholders in blocks with dangerous cladding have had their properties valued nil, making it impossible for them to sell or remortgage. This issue was raised with us many times in written evidence from across the sector and confidentially from residents.54 …
Response attribution not verified
#16 —
Recommendation: Additional costs may also arrive through wider fire safety issues discovered during remediation works and need correction. The National Audit Office found that cladding inspection has revealed other significant flaws in construction and fire safety in many 42 Ministry of …
Response attribution not verified
#14 —
Recommendation: Living in unsafe buildings has clearly impacted residents’ mental well-being. According to a survey undertaken by UK Cladding Action Group, of the 550 residents that took part, nine out of ten leaseholders in flats with unsafe cladding say their mental …
Response attribution not verified
#27 —
Recommendation: We recommend HSE ensures its current review of the Control of Asbestos Regulations includes a thorough written assessment of moves towards more stringent asbestos 52 The Health and Safety Executive’s approach to asbestos management occupational exposure limits in Europe. It …
Response attribution not verified
#26 —
Recommendation: HSE has an important role in monitoring international developments in approaches to managing asbestos risk, assessing the balance of evidence, and commissioning its own research to understand workplace patterns of asbestos exposure and behaviour. The direction of travel in Europe …
Response attribution not verified
HSSIB safety recommendations(8)
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHS England and NHS Improvement reviews the principles of the hierarchy of controls in its health building notes (HBN) and health technical memoranda (HTM) for the design of the built environment in existing and new hospital …
Safety Recommendation
Never events: analysis of HSIB's national investigations
Piped supply of medical air and oxygen (Healthcare Safety Investigation Branch, 2019a).
Learning Prompt
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
Those involved in the design of new and upgraded built environments for mental health inpatient settings can improve patient safety and the delivery of therapeutic care by involving relevant stakeholders in design processes. Stakeholders include people with lived experience (patients …
Safety Observation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
HSSIB recommends that the Department of Health and Social Care, with input from stakeholders including NHS England, identifies the short-, medium- and long-term requirements of NHS mental health built environments to ensure they enable delivery of safe and therapeutic care …
Safety Recommendation
Oxygen issues during the COVID-19 pandemic
The Trust procured pipeline flow meters and electronic telemetry to allow active monitoring of flow rates across the hospital estate.
Safety Action
Oxygen issues during the COVID-19 pandemic
It may be beneficial if medical gas pipeline systems were prioritised for financial investment and ongoing management where they may not be effective for future anticipated clinical needs.
Safety Observation
Oxygen issues during the COVID-19 pandemic
HSIB recommends that NHS England and NHS Improvement completes ongoing work to review, revise and reissue the health technical memorandum (HTM) for medical gas pipeline systems (MGPS). An updated HTM should reinforce multidisciplinary team working and include: Updated advice on …
Safety Recommendation
Mental health inpatient settings: Creating conditions for the delivery of safe and therapeutic care to …
Those involved in healthcare research can improve patient safety by seeking to understand the design principles for mental health inpatient settings that underpin safe and therapeutic care. Research should include consideration of sensory environments, the role of technology, and the …
Safety Observation
NCEPOD recommendations(1)
CQC inspection actions(256)— showing 50 strongest matches
Worthing Hospital
The trust must ensure equipment in ward environments is moved and stored in a suitable location and avoids emergency exits being blocked.
Must Do
William Harvey Hospital
The trust should ensure ward areas are always tidy and clutter-free.
Should Do
William Harvey Hospital
The trust should ensure patient equipment is maintained well and can be cleaned in between patient use.
Should Do
William Harvey Hospital
The trust must ensure cooling equipment for the SCBU is properly maintained, and risk assessed for Infection Prevention and Control and records are maintained to support this.
Must Do
William Harvey Hospital
The trust must ensure the environment in the Special Care Baby Unit (SCBU) is kept at a suitable temperature.
Must Do
William Harvey Hospital
The trust must ensure chemicals that are hazardous to health (COSHH) are stored safely and securely.
Must Do
William Harvey Hospital
The trust must make sure equipment, such as resuscitation trolleys, are safe to use and accurately checked daily to ensure they are in working order.
Must Do
William Harvey Hospital
The trust must ensure chemical products hazardous to health (COSHH) are stored safely and securely.
Must Do
William Harvey Hospital
The trust must ensure that the premises are appropriately maintained and fit for purpose. For example, ensuring reception and assessment areas are fit for purpose and risk assessed, escalation areas are appropriately risk assessed and completing required maintenance on the …
Must Do
Westmorland General Hospital
The service must ensure all equipment is properly maintained and that staff do not use equipment that is not safe nor used for its intended purpose. Specifically, they should not use a domestic bath to support water birth. All staff …
Must Do
West Cumberland Hospital
The trust must ensure that all premises and equipment used by patients are clean, secure, suitable for the purpose for which they are being used for and properly maintained.Regulation15(1)(a)(e).
Must Do
The York Hospital
The trust should ensure that monitoring and action plans are in place should water checks and legionella checks fail.
Should Do
The York Hospital
The service must ensure the maintenance of the theatre environment meets the national standards. They must ensure they are both fit for purpose, inspected yearly and actions instigated.
Must Do
The York Hospital
The service must ensure both theatres are serviced, maintained, and fit for purpose in line with best practice guidance.
Must Do
The York Hospital
The service must ensure their new ED has sufficient side rooms for medical staff to see and treat patients, barriered isolation rooms for infectious patients, handwash basins and storage areas for equipment.
Must Do
The York Hospital
The trust must ensure that high level risks, particularly in relation to estates are fully assessed and mitigated to the lowest level of risk.
Must Do
The Princess Royal Hospital
The service should ensure fire doors are in good working order at all times.
Should Do
Southampton General Hospital
The trust should consider how it maintains oversight of window restrictor durability outside of the annual checking programme.
Should Do
Southampton General Hospital
The trust should ensure that a clear and documented process is used to complete a visual inspection of window safety and that this is consistently applied.
Should Do
Southampton General Hospital
The trust board must ensure they have oversight regarding window safety across all trust sites.
Must Do
Scarborough Hospital
The trust must ensure that there is sufficient space around patient beds, with oxygen and suction placed by every bed.
Must Do
Scarborough Hospital
The service must ensure their new ED has sufficient side rooms for medical staff to see and treat patients, barriered isolation rooms for infectious patients, handwash basins and storage areas for equipment.
Must Do
Scarborough Hospital
The trust must ensure that high level risks, particularly in relation to estates are fully assessed and mitigated to the lowest level of risk.
Must Do
Royal Victoria Infirmary
The service must ensure premises are safe. This includes but is not limited to ensuring storeroom doors are not left open or unlocked.
Must Do
Royal Victoria Infirmary
All premises and equipment used by the service provider must be secure and suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This …
Must Do
Royal Victoria Infirmary
The service must ensure that all gas cylinders are stored securely.
Must Do
Royal Victoria Infirmary
All premises and equipment used by the service provider must be secure and suitable for the purpose for which they are being used, properly used, properly maintained, and appropriately located for the purpose for which they are being used. This …
Must Do
Royal Victoria Infirmary
The service must ensure that all gas cylinders are stored securely.
Must Do
Royal Victoria Infirmary
The trust must ensure that all premises and equipment are clean, secure, suitable for the purpose for which they are being used, properly used and properly maintained. This includes but is not limited to daily checks of emergency equipment and …
Must Do
Royal Sussex County Hospital
The trust must ensure that all ventilation recommendations associated with the external audit of general theatres are implemented.
Must Do
Royal Shrewsbury Hospital
The trust should ensure the mortuary viewing glass is fit for purpose.
Should Do
Royal Preston Hospital
The service should ensure that premises are safe to use for patients.
Should Do
Rochdale Infirmary
The trust must ensure that equipment is maintained in a timely manner and daily checks are completed so that staff have assurance that equipment is safe to use.
Must Do
Rochdale Infirmary
The trust must ensure that daily safety checks of equipment are fully completed.
Must Do
Rochdale Infirmary
The trust must ensure that equipment is maintained in a timely manner and staff have assurance that it safe to use.
Must Do
Rochdale Infirmary
The service must ensure all areas of the department are suitable and properly maintained. This includes but is not limited to the size and design of the department and rooms used for assessing a patient’s mental health.
Must Do
Queen's Hospital
The service must improve the safety of the rooms used for paediatric mental health patients.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure fire extinguishers are maintained correctly
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure chemical products hazardous to health (COSHH) are stored safely and securely.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must make sure equipment, such as resuscitation trolleys, are safe to use and checked daily to ensure they are in working order.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure fire escape routes are kept clear and fire doors are always kept closed.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that fire safety risks associated with an overcrowded department are assessed and mitigated. For example, with regard to trolleys blocking corridors and fire exits.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure that the premises are appropriately maintained and fit for purpose. For example, ensuring reception and assessment areas are fit for purpose and risk assessed, escalation areas are appropriately risk assessed and completing required maintenance on the …
Must Do
Pilgrim Hospital
The trust should ensure that safety checks of new ward environments are fully completed before moving patients.
Should Do
Mount Vernon Cancer Centre
The trust should ensure faults with the physical environment and premises are reported and fixed in a timely manner, including reported faults with the main entrance fire door.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that a review of the layout and environment is undertaken to improve access for patients with mobility problems and access to necessary equipment in an emergency.
Should Do
Mount Vernon Cancer Centre
The trust should ensure that all substances that are subject to control of substances hazardous to health (COSHH) regulations are stored securely.
Should Do
Montagu Hospital, Mexborough
ThetrustshouldensuretheMIUambulance/resuscitationroomisprotectedfromfloodriskanddoesnotpreventpatientswhoneedemergencycarefromaccessingtreatmentonsite.
Should Do
Montagu Hospital, Mexborough
Thetrustshouldensurethatlegionellaactionplansfortheantenatalclinicareinplaceandupdatedsoanyactionsidentifiedarerespondedtoquickly.
Should Do
Montagu Hospital, Mexborough
Theservicemustensurepremisesandenvironmentaresafeandsecure.ThisincludesCOSHHcleaningchemicalsbeingsafelystored.Regulation12(1)(2)(d).
Must Do
ICIBI immigration recommendations(1)
PPO death in custody recommendations(2)
The Governor of The Mount
The Governor of The Mount should ensure that body-worn video cameras are properly maintained and ready for use when necessary.
The Governor
The Governor should review the provision of CCTV footage and ensure the system works and is able to provide footage to relevant stakeholders, including the Ombudsman.
IOPC learning recommendations(2)
National recommendation - National Police Chiefs' Council, May 2022
The IOPC recommends that the NPCC should communicate to police chiefs, custody leads and fleet leads the importance of regularly conducting safety checks of cage van doors to ensure locking mechanisms are in working order. This recommendation follows a death …
Recommendation - Hertfordshire Constabulary, March 2021
The IOPC recommends that the National Association for Police Fleet Managers (NAPFM) shares advice and guidance on the use of finger trap shields in police vehicles. This should specifically relate to any vehicle fitted with a cage used to transport …
IMB annual reports(2)
The Verne (2025)
HMP The Verne is a Category C training prison for men convicted of sexual offences, housing 645 prisoners at the end of the reporting period. The Board found it generally safe and humane, commending healthcare, key worker improvements, and the new Building Choices program. Key concerns include staffing uncertainty, lack of 24-hour clinical cover, and the impact of budget cuts on education and purposeful activity.
PRISON
Key concerns
Ford (2025)
HMP Ford, a Category D open prison, continues its focus on rehabilitation and resettlement amidst significant challenges. The prison has seen a rise in high-risk prisoners and increased population churn, while facing persistent issues with failing infrastructure and substantial cuts to the education and training budget. Despite these hurdles, the IMB commends the prison for its generally safe environment, excellent healthcare provision, and ensuring all released prisoners secure accommodation.
PRISON
Key concerns
IMB individual recommendations(111)— showing 50 strongest matches
Dungavel House (2023)
As has been mentioned in previous reports, consideration should be given to installing robust preventative measures to ensure that roofs are not accessible to detained persons. This would help towards the safety of residents and staff. This remains an issue due to the accessibility of the fire escape stair.
Governor / Director
Wormwood Scrubs (2024)
What further support will the Minister provide to rectify issues with the antiquated buildings and infrastructure to improve living conditions and safety in the prison?
Other
In Progress
Lewes (2020)
The Board encourages the Governor to redouble efforts to improve the accommodation conditions for prisoners, and to ensure that funding from the ‘clean and decent’ project results in cleanliness being a higher priority.
Governor / Director
In Progress
Heathrow Immigration Removal Centre (2020)
The Home Office should investigate the on-going issues with regard to heat and cold on both sites and support the Contractor by providing funding to undertake major capital works if needed to resolve them and create a more appropriate environment.
Home Office
Bure (2020)
Will the Governor ensure that work is done on the ventilation system on residences 1 to 6 as a matter of priority?
Governor / Director
In Progress
Rochester (2022)
The accommodation at HMP/YOI Rochester is very poor, and in the Board’s view, just about providing a minimal standard of accommodation. The Edwardian buildings on the old site are dilapidated and challenging to keep maintained; and the newer pre-fabricated buildings have exceeded their original use dates by several years, and are beset with poor ventilation as well as ongoing water …
HMPPS
In Progress
Kirkham (2023)
The IMB would like to see the remaining unused buildings removed in a timely manner due to safety implications. When will the Prison Service arrange for this to be done?
HMPPS
Ford (2023)
There has been some welcome refurbishment of the shower/toilet facilities on several corridors. However, the continuing failure to adequately maintain the prison estate to an acceptable level leads us to question what actually needs to happen before a full refurbishment plan is drawn up and executed for A, R and Q wings, in particular. The Board is concerned that the …
HMPPS
The Verne (2024)
The Governor to ensure that the kitchen roof is repaired as a matter of urgency.
Governor / Director
Ford (2024)
A consistent, reliable heating and water supply to the accommodation blocks, as the situation is unacceptable.
Governor / Director
Partially Accepted
Preston (2025)
We have repeatedly raised concerns about the fabric of this Victorian prison. The reception area and the gatehouse are not fit for purpose and the offender management unit’s prefabricated structure was condemned 15 years ago. Despite previous responses acknowledging these problems, there has been no apparent progress to address this or secure alternative solutions in the past year. What is …
Ministry of Justice
In Progress
Ford (2025)
As we have reported for some years, the building infrastructure across Ford is failing, with each occurrence being addressed with short-term fixes, which, in the long run, cost the taxpayer more. Will the Minister commit to both undertaking a detailed survey and investigation of the existing fabric and services and to setting out a clear timetable for the development and …
Ministry of Justice
Partially Accepted
Gartree (2020)
Will the minister seek to provide a sufficient budget for HMP Gartree to create a safe living standard that would be deemed acceptable in the wider community? It continues not to be acceptable to expect staff and prisoners to live and work in buildings where the infrastructure has seriously declined over several years.
Ministry of Justice
In Progress
Dungavel House IRC (2020)
The centre is secured by a fence and gates. During 2020 there was an issue with the electronics of the inner pedestrian gate. The Board strongly recommends that this gate be upgraded.
Governor / Director
Dover (2020)
The holding facilities in Dover and Folkestone are unsuitable for the numbers of detainees arriving and should be expanded or replaced as a matter of urgency.
Ministry of Justice
Bure (2020)
Will the minister ensure that resources are made available for urgent work to the ventilation system in residences 1 to 6, to improve the air quality and increase the level of ventilation, especially taking into account that prisoners are presently locked up for up to 23 hours a day owing to COVID-19 and the expectation that this situation will continue …
Ministry of Justice
In Progress
The Mount (2021)
Some investment has been made to improve the showers but more is still needed to bring them to an acceptable standard.
HMPPS
In Progress
Highpoint (2021)
The netting that blew down in the storm over a year ago at HMP Highpoint, and which has still not been mended or replaced, remains a security and safety issue. This prison is vulnerable to throw-overs, and the increased opportunity for contraband to get into the prison has a negative impact on the health and wellbeing of the prisoners.
HMPPS
Altcourse (2021)
The quality and quantity of food provided for prisoners has consistently improved over the reporting year with the welcome addition of homemade soup and a bakery on site producing bread and rolls. Also kitchen equipment is maintained in a more timely matter. However there still remains a problem with the newly installed flooring which floods frequently despite a number of …
Governor / Director
Wymott (2022)
Is the kitchen refurbishment programmed for 2022 / 23 likely to go ahead?
HMPPS
Noted
Winchester (2022)
Given the continued impact of the vermin infestation, and the associated health and safety concerns, what more lasting and impactful arrangements can be made to resolve this issue?
Governor / Director
Winchester (2022)
As many cells still get very hot in summer and very cold in winter, and showers are often non-functioning due to an outdated fabric and design, what are the Prison Service’s plans for resolving these issues?
HMPPS
In Progress
Heathrow Immigration Removal Centre (2022)
It is our view that the Cedar and Dove units in Harmondsworth, hostel-style units with showers and toilets at the ends of corridors, need significant investment to bring them into line with the rest of the Harmondsworth estate. We understand that these units are slated for an overhaul in 2025-2026 but consider that this timing is too protracted and that …
Ministry of Justice
Wormwood Scrubs (2023)
What resources will the Minister make immediately available to this prison to improve the fabric of the prison?
Ministry of Justice
Long Lartin (2023)
Prison infrastructure, maintenance and projects. Will the Minister acknowledge that the prison infrastructure is now so degraded that effective routine maintenance is no longer possible and that a major modernisation project is required in the near future?
Ministry of Justice
In Progress
Leicester (2023)
Can funds be found for repair of the fabric of the building and replacement of equipment?
HMPPS
Huntercombe (2023)
When will the Prison Service facilitate the urgent upgrading of the antiquated heating and hot water systems?
HMPPS
In Progress
Heathrow immigration removal centre (2023)
Ventilation systems within the Heathrow IRC needs a thorough overhaul as some wings are extremely hot or cold. There appears to be little that can be done to regulate the temperature.
Governor / Director
Gartree (2023)
Can the Minister confirm that new funding bids will be supported, and budgets will be allocated to address the seriously deteriorating fabric and infrastructure of Gartree, regardless of the confirmation that a new prison will now be built next to Gartree?
Ministry of Justice
Deerbolt (2023)
Many ageing establishments, including Deerbolt, require significant investment for maintenance and upkeep. How does the Minister plan to secure ample funding for this purpose?
Ministry of Justice
In Progress
Channings Wood (2023)
The Board has observed the steady and detrimental impact of acute population pressures across a range of prison services. The planned expansion at Channings Wood is part of the national programme intended to address this. Can the Minister assure the Board that the provision of new infrastructure will not be at the expense of maintaining the current and ageing estate? …
Other
Bedford (2023)
Prisoners have regularly reported issues about pigeon droppings, cockroaches, showers not working and broken tumble dryers.
Governor / Director
Swaleside (2024)
The issue of overflowing sewage from the drains must be addressed as this is exposed to the movement of food trolleys to the residential areas, which is a Health and Safety issue.
Governor / Director
Standford Hill (2024)
The condition of some of the buildings on site is not good and additional funding needs to be obtained to ensure this is addressed.
Governor / Director
Noted
Standford Hill (2024)
The unsafe buildings within the Standford Hill estate need to be made safe and additional facilities made available. We consider the response to this possible health and safety situation so far to have been unacceptable and, indeed, too slow.
HMPPS
In Progress
Portland (2024)
Will HMPPS, as a matter of urgency, arrange for the necessary funding to be made available to address the ventilation issues that exist on Beaufort wing during spells of hot weather and the funding to address the repairs required to re-open the laundry facility, which relies on another prison to deliver these services?
HMPPS
In Progress
Liverpool (2024)
Will the Prison Service invest in resetting the CCTV equipment to a usable monitoring performance standard and maintain it at this level?
HMPPS
Implemented
Lewes (2024)
Urgently improve living conditions at HMP Lewes through better repair and maintenance services.
HMPPS
In Progress
Cardiff IMB (2025)
Beth yw'r amserlen ar gyfer mynd i'r afael â chyflwr gwael rhannau o ystâd y carchar, cau parhaus yr adeiladau sydd wedi'u marcio ar gyfer eu dymchwel, a phroblemau parhaus gyda seilwaith sylfaenol fel gwresogi, dŵr poeth a ffonau?
HMPPS
Cardiff (2025)
What is the timeline for addressing the poor condition of parts of the prison estate, the continued closure of buildings marked for demolition, and ongoing problems with basic infrastructure such as heating, hot water and phones?
HMPPS
In Progress
Brinsford (2023)
There is a long-standing leak in the reception area. The Board has been aware of the leak for two years, if not longer, but it continues to be a major problem. Many hours are spent cleaning up the stained and smelly water as is trying to secure money for the work to be completed. In the meantime, money is spent …
Ministry of Justice
Derwentside (2024)
To improve the communications infrastructure for Derwentside
Home Office
In Progress
Werrington (2020)
Can the minister guarantee that investment will be available to convert inadequate old buildings such as those at HMP/YOI Werrington into effective secure schools?
Other
Noted
Stoke Heath (2020)
The Board considers that funding needs to be allocated for Stoke Heath as a matter of urgency to improve telephone access for prisoners.
HMPPS
In Progress
Pentonville (2020)
Will the Prison Service deliver essential refurbishment for decency, such as toilets and showers?
HMPPS
In Progress
Lincoln (2020)
A decision should be made on whether or not funds will be provided to repair or replace the long-out-of-action main lift (see paragraph 5.9).
HMPPS
In Progress
Garth (2020)
Pressure should be brought to cause the transport providers urgently to address this issue, perhaps by changing the design of their vehicles or by adding secure trailers.
HMPPS
Partially Accepted
Dungavel House IRC (2020)
The escorting contract is held by Mitie who have an office and a vehicle base in the car park of the centre. This by default, has led to a much reduced number of parking bays for GEO staff and visitors. This must be addressed.
Governor / Director
Downview (2020)
Sufficient funding should be provided to procure heating and electrical supplies that are reliable and fit for purpose for all the accommodation blocks (see section 5.1).
HMPPS
In Progress
Dover (2020)
Ventilation in the holding rooms should be improved.
Other
Health investigations(5)
Investigation into matters relating to Jimmy Savile at Leeds General … — Rec 17
The Trust should review security across all sites, including on-call residences and decommissioned areas in its estate, to develop a comprehensive strategic security plan. The Board should seek regular assurance that all restricted areas are secure, including high-risk areas (source: chapters six and eight).
Leeds Teaching Hospitals NHS Trust
north_east_yorkshire
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec q.
That the security arrangements at Newbridge House, and the arrange- ments there for protecting the physical safety of staff and patients, are immediately independently reviewed.
midlands
Independent investigation: Eshun Marnade Chattun, Springfield hospital Tooting (2003) — Rec 6
The Trust should audit and review response times from its Estates Department to requests for repairs in areas where patients may be at high risk.
london
Independent investigation: Adel Makar, Westcliff on Sea (2006) — Rec 23
The Orchard Unit Management Team should consider the environment, including the provision of furniture which is difficult to move; and the consistent use of non-breakable crockery and cutlery to reduce patient and staff injury.
east_of_england
An Independent Review into the care and treatment provided by … — Rec 5
The Trust needs to have a better understanding of the quality of its estate and the impact of this on the delivery of high-quality care, including providing a safe environment. It must ensure that essential maintenance is identified and carried out in a timely manner and that the cleanliness of …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Scottish Fatal Accident Inquiries(31)
Richard King and Roland Michael Duffell
In the light of my foregoing conclusions, I now offer the following recommendations:- • there are a number of matters which I would like to see considered as a matter of urgency by the committee responsible for British Standards in relation to flame cutting and welding equipment and hoses carrying both oxygen and flammable gases, namely;- • the elimination of …
Feb 2002
Christine Jane Foster
1. that the City of Edinburgh Council carries out an immediate audit of those buildings within the city thought to constitute a risk to public safety, insofar as such audit has not yet commenced, so that existing statutory powers to ensure proper standards of safety can be exercised; and 2.that the Council take appropriate steps to remind those responsible for …
Feb 2002
John Kelly
I recommend that Hindle consider Dr Joel's findings and consider whether any revision to the manufacturing process is necessary. I recommend that steps be taken to address this issue.
Mar 2004
Thomas Connolly
The Health & Safety Executive and the relevant bodies such as the Construction Industry Training Board (CITB), the Construction Industry Research and Information Association (CIRIA) and the Institute of Civil Engineers should all take steps to ensure that industry guidance and training courses (for both managers and operatives) are updated to include reference to the circumstances of this accident, namely …
Oct 2006
Gordon Love Robertson
In terms of section 6(1)(e) recommends that consideration be given by those responsible for the warning signs on the bank of the river adjacent to the Holiday Park as to whether it would be appropriate to include a sign warning users of the banks of the river adjacent to the Holiday Park of the dangers posed by the artificial fluctuation …
May 2007
Bruce Scott Thomson
In that event it was suggested i) that the sign containing the msl should be replicated on the right hand side of the barrier (approaching from the A9), ii) that the 110 sign should be replicated at the low-level buttons, and iii) that there should also be an audible warning at the low-level buttons. The evidence of Mr Gray, that …
Nov 2001
John Andrew McCafferty
I would have thought that serious consideration should be given by anyone owning a caravan to having such a device installed. I would have thought that the same regulations that apply to other caravans and homes should apply to touring caravans to try and ensure that persons working on gas appliances in touring caravans are Corgi registered. I would have …
Mar 2009
Muireann Caitlin McLaughlin
[61] I recommend that in the formulation of appropriate regulations consideration be given to banning the use of looped blind cords at all but not so as to create other, different hazards or to render blinds effectively inoperative. Safety warnings permanently attached to cords along with conspicuous warnings for the purchaser / supplier / fitter; [65] I recommend that BERR, …
May 2009
James Robert Hutchinson
I therefore recommend that drivers should be provided with a head torch if it is not reasonably practicable to provide fixed lighting.
Jul 2009
Ben Harry Robert McCreath
To protect against this , openings in a protective barrier should prevent the passage of a 100mm diameter sphere “ I recommend that the 100 mm rule should be applied to all non-domestic buildings and not only such buildings where the presence of children is anticipated. That should be the default setting and designers/architects/developers and their agents would require to …
May 2010
Alexander William Riddoch
In my view, this Inquiry has drawn attention to a state of matters affecting the supply of electrical power across the country which does require to be examined more closely. In view of the variety of social and economic conflicting interests involved it may be that there will require to be a multi- agency nationally based systematic enquiry and analysis …
Aug 2010
Ramilto Capangpangan Calipayan, Benjamin Rosillo Potot and Rimants Venckus
Accordingly I make the following recommendations:- ` (i) base unit fan heaters should no longer be fitted in fishing vessels; B9/10 Pf Peterhead V R Calipayan,B Potot And R Venkcus (ii) in the event of a base unit fan heater, currently fitted in a fishing vessel, ceasing to operate due to a component failure, the entire base unit fan heater …
Aug 2011
John Campbell MacKinnon
In the circumstances where a vehicle strikes an overhead power line, the safest course of action for a driver or other occupant is to remain within the vehicle unless it ignites in which case he should jump out of it without touching the exterior of the vehicle and “bunny-hop” away from it keeping both feet as close together as possible …
Jan 2014
Keane Grace Wallis Bennett
All reasonable steps should be taken to reinforce that warning to ensure that measures are taken in both the public and private domain to assess the risk of the continued use of such walls with associated guidance on remedial measures which can be taken to promote safety and stability which failing safe and effective removal of such walls from use …
Aug 2017
Ciaran James Williamson
1. I recommend that the Scottish Government issue separate guidance on memorial safety in cemeteries for use by local authorities throughout Scotland. Such guidance should include a category of advice on how to inspect large, traditional monuments such as the Ross memorial, as distinct from lawn memorials and other smaller structures. Given the potential danger posed by large leaning memorials, …
Jan 2018
Martin Leonard Buchan
Aug 2019
Peter Gray
1. In terms of section 26(4)(a), deck dividers should be used in fishing vessels to keep crew clear of a running back rope. 2. In terms of section 26(4)(d): a) Those who operate fishing vessels should install ladders, overside tyres or other safety measures to ensure there is a means to re-enter the vessel once a person has gone overboard. …
Jan 2023
Harjvan Bhikhabhai Kharva and Ravindra Shavirang Bagal
I adopt his submission and recommend that Orkney Harbour Authority should review its rules with a view to ensuring that there is no scope for ambiguity as to whether or not it is a port requirement that ships should have an anchor ready for use when within Orkney Harbour limits whether or not a vessel is under pilotage. If such …
Jun 2009
Rosepark Care Home
That there should be such an external check by a regulator. (4) Consideration should be given to the proposal of SF&R that the smoke and fire integrity of compartments (which would include but would not be limited to the presence and effectiveness of dampers, if so fitted) be subject to expert certification in the same way as the electrical installation …
Apr 2011
Christopher Moses
Aug 2022
Simon Midgley; Richard John Dyson
Owners or operators of hotels or similar sleeping accommodation in Scotland should, where appropriate to their operation, have in place up to date and robust procedures, informed by an assessment of risks, to ensure that ash from open fires in hotels is removed and disposed of in a safe manner, thereby avoiding the risk of fires being started by the …
Jan 2023
Other
6 recs
John Pryde
Feb 2023
John Norman Murray
a. The Health and Safety Executive (hereinafter called ‘HSE’) should consider investigating the photographic examples provided to the Inquiry by Mr Watkins showing mobile scaffolding towers were being used inappropriately. b. The HSE should consider whether current guidance regarding the inappropriate use of mobile scaffolding towers as i) a means of access; and ii) edge protection; can be improved or …
Jun 2023
Wallace Hunter
Jul 2025
Raymond James Birse
There are high risks involved in dismantling buildings and structures, and in this instance, the structure was over 45 years of age. There is merit in the HSE inspector’s observation that such a potentially dangerous activity should only be undertaken by contractors with expertise in this type of work. The system that was adopted by Mr Birse on the day …
Sep 2007
Gordon Turriff
8.4 Instead I recommend that there should be a review by Mintlaw Transport Limited, in consultation with the Health and Safety Executive, as to the method by which any B192/09 PF Peterhead v Gordon Turriff problem which might arise with, say, the cover of such a partially filled trailer might safely be dealt with without resort to entering the trailer. …
Oct 2009
Andrezej Freitag
I urge that there be improvements in the certification of competent staff and the policing of health and safety legislation.
Apr 2010
Joy Paula Robson, John Leonard Stern, Elizabeth Allan, Iain John Provan
A. The organisers of the Snowman Rally and generally the organisers of rallies with forest stages, should in all of their pre-event publicity ensure that potential spectators are fully and properly advised of the geography of more remote locations, are clearly directed to safe viewing areas, and are actively discouraged from entering potentially difficult or dangerous viewing locations. B. That …
Nov 2017
James Darren Kerr
The Sheriff, having considered the information presented at the inquiry, makes the following recommendation in terms of 26(1)(b) of the Act: 1. That the Health and Safety Executive opens an investigation into how grade 6 locknuts incorrectly designated as being of the higher grade |8| strength came to enter the supply chain; and whether any ongoing risk to safety arises …
Apr 2021
Philip Reid
In terms of sections 26(1)(b) of the 2016 Act (recommendations (if any) as to the taking of any other steps, which might realistically prevent other deaths in similar circumstances): That the Health and Safety Executive ensure that sufficient information is available and communicated effectively so that those involved in construction and demolition works in relation to agricultural premises are aware …
Jun 2021
Pawel Kocik
In terms of sections 26(1)(b) of the 2016 Act (recommendations (if any) as to (a) the taking of reasonable precautions, (b) the making of improvements to any system of working, (c) the introduction of a system of working, (d) the taking of any other steps, which might realistically prevent other deaths in similar circumstances) It is recommended that the Health …
Sep 2022
Independent reviews(50)
Acheson Report — Rec 28
We RECOMMEND the quality of homes in which older people live be improved. Specifically:
Health & Social Care
Pitt Floods Review — Rec 73
The Government, the Association of British Insurers and other relevant organisations should work together to explore any technological or process improvements that can be made to speed up the drying out and stabilising process of building recovery after a flood.
Other
Pitt Floods Review — Rec 58
The Government should implement the legislative changes proposed in the Environment Agency biennial report on dam and reservoir safety through the forthcoming flooding legislation.
Other
Pitt Floods Review — Rec 57
The Government should provide Local Resilience Forums with the inundation maps for both large and small reservoirs to enable them to assess risks and plan for contingency, warning and evacuation and the outline maps be made available to the public online as part of wider flood risk information.
Other
Pitt Floods Review — Rec 55
The Government should strengthen and enforce the duty on Category 2 responders to share information on the risks to their infrastructure assets, enabling more effective emergency planning within Local Resillience Forums.
Other
Pitt Floods Review — Rec 54
The Government should extend the duty to undertake business continuity planning to infrastructure operating Category 2 responders to a standard equivalent to BS25999, and that accountability is ensured through an annual benchmarking exercise within each sector.
Other
Pitt Floods Review — Rec 53
A specific duty should be placed on economic regulators to build resilience in the critical infrastructure.
Other
Pitt Floods Review — Rec 52
In the short-term, the Government and infrastructure operators should work together to build a level of resilience into critical infrastrucure assets that ensures continuity during a worst-case flood event.
Other
Pitt Floods Review — Rec 51
Relevant government departments and the Environment Agency should work with infrastructure operators to identify the vulnerability and risk of assets to flooding and a summary of the analysis should be published in Sector Resilience Plans.
Other
Pitt Floods Review — Rec 50
The Government should urgently begin its systematic programme to reduce the disruption of essential services resulting from natual hazards by publishing a national framework and policy statement setting out the process, timescales and expectations.
Other
Pitt Floods Review — Rec 45
The Highways Agency, working through Local Resilience Forums, should further consider the vulnerability of motorways and trunk roads to flooding, the potential for better warnings, strategic road clearance to avoid people becoming stranded and plans to support people who become stranded.
Other
Pitt Floods Review — Rec 7
There should be a presumption against building in high flood risk areas, in accordance with PPS25, including giving consideration to all sources of flood risk, and ensuring that developers make a full contribution to the costs both of building and maintaining any necessary defences.
Other
Naylor Review — Rec 9
STPs should develop affordable estates and infrastructure plans, with an associated capital strategy, to deliver the 5YFV and address backlog maintenance. These plans should be supported by robust business cases. The new NHS Property Board should support the development of these plans.
Health & Social Care
Hackitt Review — Rec 9.3
For HRRBs the information in the contracting documentation relating to the safety aspects should be included in the digital record set out in Chapter 8.
Building Safety
Accepted
Hackitt Review — Rec 9.2
a. For HRRBs, tenders should set out how the solution that is proposed will produce safe building outcomes, approaching the building as a system. Those procuring should use the tender review process to test whether this is the case. b. The government should consider applying this requirement to other multi-occupancy …
Building Safety
Accepted
Hackitt Review — Rec 9.1
a. For higher risk residential buildings (HRRBs), principal contractors and clients should devise contracts that specifically state that safety requirements must not be compromised for cost reduction. b. The government should consider applying this requirement to other multi-occupancy residential buildings and to institutional residential buildings.
Building Safety
Accepted
Hackitt Review — Rec 8.4
a. Dutyholders must hold, transfer and update information throughout the life cycle of the HRRB. b. Information from this record is to be provided to the JCA in the event that this may be required.
Building Safety
Accepted
Hackitt Review — Rec 8.3
a. Government should work with industry to agree the type of information to be collected and maintained digitally (by default) to enable the safe building management of existing HRRBs. b. Dutyholders must identify and record where gaps in the above information exist and the strategy for updating that relevant information.
Building Safety
Accepted
Hackitt Review — Rec 8.2
Government should work with industry to agree what information must be held in the digital record for new HRRBs.
Building Safety
Accepted
Hackitt Review — Rec 8.1
a. Government should mandate a digital (by default) standard of record-keeping for the design, construction and during the occupation of new HRRBs. This is to include any subsequent refurbishments within those buildings. b. Digital records are to be in a format which is appropriately open and non-proprietary with proportionate security …
Building Safety
Accepted
Hackitt Review — Rec 7.6
a. Government should ensure that there is a more effective enforcement, complaint investigation and market surveillance regime with national oversight to cover construction product safety. b. Government should consider whether this could be achieved by extending the remit of the Office for Product Safety and Standards. c. The introduction of …
Building Safety
Accepted
Hackitt Review — Rec 7.3
A simpler, more streamlined set of standards relating to the testing of products used in HRRBs, and the health and safety of people in and around those buildings, needs to be developed. This should ensure that where new standards are required, these are identified quickly and in the case of …
Building Safety
Accepted
Hackitt Review — Rec 7.2
a. Manufacturers must retest products that are critical to the safety of HRRBs at least every three years. Manufacturers should consider the need to test more frequently, focusing especially on the testing of products as they operate in systems rather than individual elements. b. The testing of products that are …
Building Safety
Accepted
Hackitt Review — Rec 7.1
a. A clearer, more transparent and more effective specification and testing regime of construction products must be developed. This should include products as they are put together as part of a system. b. Clear statements on what systems products can and cannot be used for should be developed and their …
Building Safety
Accepted
Hackitt Review — Rec 6.3
The Government should take forward the recommendations made by the Expert Group included at Appendix F. To summarise these are: a. clear user friendly language and formatting of the guidance (including Approved Document B); b. multiple points of entry for different users to the document set, to provide clear advice …
Building Safety
Accepted
Hackitt Review — Rec 5.4
Relevant parties should work together, along with the relevant professional bodies, to develop and define a robust, comprehensive and coherent system for: a. the competence requirements for the role of building safety manager of HRRBs; and b. the remit of this role in introducing and overseeing the process by which …
Building Safety
Accepted
Hackitt Review — Rec 4.6
a. The dutyholder for a HRRB should provide residents with clear information about their obligations in relation to building and fire safety, and residents should meet their obligations to ensure their own safety and that of their neighbours. b. The government should consider applying this requirement to other multi-occupancy residential …
Building Safety
Accepted
Hackitt Review — Rec 4.5
a. After internal processes have been exhausted, if residents still have safety concerns about their homes, there should be a clear and quick escalation and redress route available for residents of all tenures to an independent body with access to appropriate knowledge, resources and enforcement powers. b. This route of …
Building Safety
Accepted
Hackitt Review — Rec 4.2
a. Residents of HRRBs should have the right to access fire risk assessments, safety case documentation and information on maintenance and asset management that relates to the safety of their homes. b. The government should consider applying this requirement to other multi-occupancy residential buildings.
Building Safety
Accepted
Building Control Independent Panel — Rec 8
Consider introducing mandated minimum inspections for standard build types. Set nationally agreed inspection points at key stages in construction of a building, so that work receives consistent, risk appropriate oversight.
Building Safety
Cunliffe Water Commission — Rec 68
Recommendation 68: The regulator's oversight of infrastructure resilience and asset health should be strengthened, under its supervisory approach. This should include the appointment of a Chief Engineer on the board of the regulator in England and Wales respectively.
Other
Cunliffe Water Commission — Rec 67
Recommendation 67: The UK and Welsh Governments should strengthen the requirements on companies to map and assess the health of their assets, and the regulator should ensure metrics for asset health are sufficiently forward-looking.
Other
Cunliffe Water Commission — Rec 66
Recommendation 66: Statutory resilience standards, covering system, infrastructure and supply chains, should be developed and adopted for the water industry in England and Wales. Resilience standards should ensure all companies make forward-looking, long-term assessments of their systems and assets and of their ability to recover from disruption to their network.
Other
Cunliffe Water Commission — Rec 19
Recommendation 19: The regulator should ensure funding directed appropriately to maintain assets by clearly defining and ring-fencing base capital expenditure (capital maintenance), base operational expenditure and enhancement capital expenditure allowances. This applies to England and Wales.
Other
Acheson Report — Rec 12.2
We recommend amending housing and licensing conditions and housing regulations on space and amenity to reduce accidents in the home, including measures to promote the installation of smoke detectors in existing homes.
Health & Social Care
Pitt Floods Review — Rec 49
A national flooding exercise should take place at the earliest opportunity in order to test the new arrangements which central government departments are putting into place to deal with flooding and infrastructure emergencies.
Other
Pitt Floods Review — Rec 46
The rail industry, working through Local Resilience Forums, should develop plans to provide emergency welfare support to passengers stranded on the rail network.
Other
Pitt Floods Review — Rec 8
The operation and effectiveness of PPS25 and the Environment Agency’s powers to challenge development should be kept under review and strengthened if and when necessary.
Other
Glover Landscapes Review — Rec 12
Proposal 12: Better information and signs to guide visitors The National Landscapes Service should develop core principles of public access for all of our national landscapes, from a single helpful website, to high standards on rights of way signs and entry points. It should feel special to be in a …
Other
Wessely Review — Rec 88
The backlog of maintenance and repairs needs to be addressed so that mental health facilities are brought up to standard.
Health & Social Care
Accepted
Hackitt Review — Rec 1.1
The new regulatory framework should apply to residential properties which are 10 or more storeys high in the first instance. New HRRBs should be identified by the Local Planning Authority and notified to the regulator. Existing buildings in scope should be identified through other means, learning from the MHCLG Building …
Building Safety
Accepted
Pitt Floods Review — Rec 6
The Environment Agency and the Met Office should work together, through a joint centre, to improve their technical capability to forecast, model and warn against all sources of flooding.
Other
Pitt Floods Review — Rec 5
The Environment Agency should work with partners to urgently take forward work to develop tools and techniques to model surface water flooding.
Other
Glover Landscapes Review — Rec 16
Proposal 16: Consider expanding open access rights in national landscapes Though it is not a core part of our review, and any look at open access needs a much more in depth investigation, we think there is a case for looking at whether further access rights should be established, or …
Other
Building Better Building Beautiful Commission — Rec 33
regreen streets and squares. Other actions which the government should support and encourage should include: • Bricks for bees and birds in new build homes; • Greenery low to the ground to capture particulate matter; • The retention of existing hedges in greenfield developments and planting of new hedges; • …
Building Safety
Selous Review — Rec 1
The Ministry of Defence to ensure that: • there is continued and urgent significant investment in poor quality SFA that is intended for occupation • remedial maintenance and high quality repairs are carried out swiftly and efficiently, and continued preventative maintenances is ongoing • The Amey call centre is better …
Other
Morecambe Bay Investigation — Rec 17
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, an improved ability to observe and respond to all women …
Health & Social Care
Naylor Review — Rec 4
The NHS Property Board should be the primary voice to the system on estate matters and should work with national bodies to ensure that the system receives clear and consistent messages about the importance of developing a modern fit for purpose estate, releasing land and addressing backlog maintenance.
Health & Social Care
Wessely Review — Rec 89
The government and the NHS should commit in the forthcoming Spending Review to a major multi-year capital investment programme to modernise the NHS mental health estate.
Health & Social Care
Accepted
Hackitt Review — Rec 7.5
a. The construction products industry should work together to develop and agree a consistent labelling and traceability system, making use of the digital technologies that are already available and learning from other sectors. b. The dutyholder for any given HRRB should ensure that the documentation that supports the performance claims …
Building Safety
Accepted
PHSO casework decisions(2)
P-002298 — Natural England
Natural England failed to police a third-party organization that wrongly granted a campsite exemption, causing safety concerns and nuisance from shared access.
UK Government
Nov 2023
P-002426 — Guy's and St Thomas' NHS Foundation Trust
Mrs A complained she suffered severe pain from a lift crash stop at Guy's and St Thomas' NHS Foundation Trust and sought investigation, apology, and financial payment.
NHS in England
Jan 2024
LGO / SPSO decisions(309)
25-019-745 — North Northamptonshire Council
Summary: We will not investigate Mrs B’s complaint about the Council leaving a walkway in an unsafe state. This is because it is unlikely an investigation would add to the Council’s own investigation and it is reasonable for Mrs B to take the Council to court if she seeks compensation.
LGO (Local Government & …
Transport And Highways
Dec 2025
22-000-935 — Thurrock Council
Summary: We will not investigate Miss X’s complaint about the Council’s failure to take action to deal with dangerous doors at a local nursery. This is because there is not enough evidence of fault by the Council and it is unlikely we could achieve any worthwhile outcome.
LGO (Local Government & …
Planning
May 2022
22-000-411 — London Borough of Hillingdon
Summary: Mr B complained that the Council had failed to take action in response to his concerns about danger caused by trees next to his property which posed a health and safety risk to himself and his family. We found no fault on the Council’s part.
LGO (Local Government & …
Environment And Regulation
Not Upheld
Aug 2022
23-014-498 — Birmingham City Council
Summary: Mr X complains the Council has failed to carry out its duty to install Public Right of Way signs in the local area. The Ombudsman finds fault with the Council for the service failure in the implementation of the signs. The Council has agreed to apologise, pay Mr X …
LGO (Local Government & …
Transport And Highways
Upheld
May 2024
25-000-760 — Stockport Metropolitan Borough Council
Summary: We will not investigate Mr C’s complaint that his property has been damaged due to the Council’s failure to maintain adjoining land. This is because it is reasonable for Mr C to take the Council to court.
LGO (Local Government & …
Other Categories
Apr 2025
24-021-137 — Brighton & Hove City Council
Summary: We will not investigate Mrs X’s complaint about damage caused by a Council owned tree and a personal injury claim for her child, Y. This is because it is reasonable for Mrs X to take the matter to court.
LGO (Local Government & …
Environment And Regulation
Apr 2025
25-001-001 — Surrey County Council
Summary: We will not investigate Mrs B’s complaint that she suffered an injury due to the Council’s failure to remove a dangerous tree. This is because it is reasonable for Mrs B to pursue her compensation claim by taking the Council to court.
LGO (Local Government & …
Environment And Regulation
Apr 2025
25-007-538 — London Borough of Southwark
Summary: We cannot investigate Mr B’s complaint that he suffered injuries after slipping on a wet floor in a Council-owned housing block. This is because we cannot investigate complaints about the management of social housing by councils.
LGO (Local Government & …
Other Categories
Jul 2025
PSOW-202101965 — Llansteffan & Llanybri Community Council
Mr X complained that Llansteffan & Llanybri Community Council (“the Community Council”) is failing in its duty to uphold the law by not using the Statutory Power at its disposal to protect the land they registered as a Village Green. Mr X also complained that the Community Council were delayed …
PSOW (Public Services Om…
Local Government
Aug 2021
22-001-427 — Royal Borough of Kingston upon Thames
Summary: We will not investigate Ms X’s complaint that the Council did not repair a streetlamp on her road. This is because there is insufficient evidence of fault and Ms X has not been caused an injustice.
LGO (Local Government & …
Transport And Highways
May 2022
22-002-045 — Manchester City Council
Summary: We will not investigate this complaint about damage caused to Mr X’s car by falling branches from a Council-owned tree which he says is not properly maintained. It is reasonable for Mr X to seek a remedy from the Council’s insurers or the courts if liability is not accepted.
LGO (Local Government & …
Environment And Regulation
May 2022
21-001-978 — Liverpool City Council
Summary: The Council is at fault for delaying its response to Mr X’s request to remove a barrier blocking access to his land. The Council has agreed to apologise and pay Mr X for the distress caused by its fault.
LGO (Local Government & …
Other Categories
Upheld
Jun 2022
22-006-017 — Middlesbrough Borough Council
Summary: We will not investigate this complaint about damage to the complainant’s property from a council owned tree. This is because it is reasonable to expect the complainant to go to court to determine any liability owed by the Council for the claimed injustice.
LGO (Local Government & …
Environment And Regulation
Aug 2022
21-018-090 — Dartford Borough Council
Summary: Mr X complained about the Council’s management of trees near his home. He said the Council had failed to complete the required maintenance work. He also complained about the way the Council responded to his concerns. We have not found fault by the Council in the way it made …
LGO (Local Government & …
Environment And Regulation
Not Upheld
Aug 2022
22-003-258 — Bristol City Council
Summary: Mrs D says the Council has failed to address refuse bins and fly tipping obstructing a pavement. The Ombudsman has discontinued the investigation because he cannot add to what the Council has already done, and further investigation would not lead to a different outcome.
LGO (Local Government & …
Environment And Regulation
Not Upheld
Aug 2022
22-012-105 — Cumbria County Council
Summary: We will not investigate this complaint about damage caused to Mr X’s fence allegedly arising from the Council’s actions and omissions. This is because it is reasonable to expect Mr X to go to court to determine any liability owed by the Council.
LGO (Local Government & …
Environment And Regulation
Dec 2022
23-018-518 — Dacorum Borough Council
Summary: We will not investigate this complaint about damage caused to Mr X’s property by development work near to his home. it is reasonable for him to seek a remedy by making a claim against the developers or the Council and to seek redress in the courts if liability is …
LGO (Local Government & …
Housing
Mar 2024
23-018-441 — Dacorum Borough Council
Summary: We will not investigate this complaint about damage caused to Mr X’s property by development work near to his home. it is reasonable for him to seek a remedy by making a claim against the developers or the Council and to seek redress in the courts if liability is …
LGO (Local Government & …
Housing
Mar 2024
23-019-293 — Elmbridge Borough Council
Summary: We will not investigate this complaint about damage to Mr X’s property from a fallen tree. If Mr X considers the Council is liable for the damage, it is reasonable for him to seek a remedy by way of an insurance claim and the courts.
LGO (Local Government & …
Environment And Regulation
Apr 2024
24-001-217 — London Borough of Bexley
Summary: We will not investigate this complaint about street lighting and 5G towers because there is not enough evidence of fault to justify investigating.
LGO (Local Government & …
Transport And Highways
Jun 2024
24-021-444 — London Borough of Newham
Summary: We will not investigate this complaint about the Council’s decision to remove a brick wall near the complainant’s home and erect a temporary metal fence. The Council confirmed the wall was removed because it was unsafe and dangerous. It confirms it is reconsidering whether a brick wall can be …
LGO (Local Government & …
Other Categories
May 2025
25-008-380 — Bolton Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s maintenance in a play area. This is because we cannot achieve the outcome that Mrs Y seeks, so there is no worthwhile outcome achievable by our investigation.
LGO (Local Government & …
Other Categories
Aug 2025
24-010-753 — London Borough of Hammersmith & Fulham
Summary: We cannot investigate Mr X’s complaint that the Council has failed to carry out work to a tree in a neighbouring property, which Mr X says has caused damage to his property. This is because the
LGO (Local Government & …
Environment And Regulation
Nov 2024
24-010-684 — Mole Valley District Council
Summary: We will not investigate this complaint about an alledged failure by the Council to maintain public areas, including parks, woodlands and highways. This is because there is insufficient evidence the complainant has directly been caused a significant enough injustice to warrant investigation.
LGO (Local Government & …
Other Categories
Nov 2024
24-010-214 — Durham County Council
Summary: We will not investigate this complaint about the Council’s handling of Mr X’s request that it carry out works to a tree and hedge close to his home. This is because there is no evidence to suggest fault by the Council.
LGO (Local Government & …
Environment And Regulation
Nov 2024
24-009-924 — Manchester City Council
Summary: We will not investigate Mr X’s complaint about damage to his property caused by Council-owned trees and shrubbery. This is because it is reasonable for Mr X to submit a claim to the Council’s insurers, and if needed take the matter to court.
LGO (Local Government & …
Other Categories
Nov 2024
201100641 — East Ayrshire Council
Mr C has since 2002 owned a flat and teashop in a three storey building. There are takeaway premises on the ground floor. Mr C first complained to the council about smells from the takeaway premises in 2003. The council suspended taking formal action about this while Mr C pursued …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Jul 2012
201103803 — Fife Council
When a school was rebuilt, a new glass fronted entrance area and carpark were created opposite Mr C's house. He found that security lights and internal lights shone into his house throughout the night, disrupting his sleep, and he complained to the council. Although it was agreed that timers would …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2013
201508523 — The City of Edinburgh Council
Ms C, a council tenant, complained about the time it took the council to deal with a problem she was having with pigeons on her balcony. Although we found the council's communication could have been better, we were satisfied that the works, which had been assessed as non-emergency, were carried …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Feb 2017
201508161 — Glasgow City Council
Miss C complained that the council failed to act on concerns she raised about possible structural damage to her home caused by works carried out on the adjoining property. She was of the view that the building control team failed in their duty to protect her and her family from …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Feb 2017
201707656 — Glasgow City Council
Mr C complained about a cafe premises near his property. The complaint included issues relating to the operation of a kitchen in the basement of the cafe and the placing of seating and tables outside the front of the cafe. In relation to the operation of a basement kitchen, Mr …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Mar 2019
202503318 — Sanctuary Cumbernauld
C complained about the condition of their adult child (A)'s property. C said that the house was impossible to heat, and constantly cold and damp. Following our decision to move the case to investigation, the association offered A a new flat. C was happy with this outcome and we closed …
SPSO (Scottish Public Se…
Housing Associations
Feb 2026
PSOW-202100791 — Newport City Council
Mrs C complained that Newport City Council (“the Council”) had failed to communicate properly with her or her agent during a planning application she made to it for an extension to her home. She stated that there had been delays in the process and that she missed the opportunity to …
PSOW (Public Services Om…
Local Government
Jun 2021
PSOW-202100029 — Carmarthenshire County Council
Mr A complained about Carmarthenshire County Council’s handling of his complaint concerning planning enforcement on a neighbouring property. Mr A said that he felt he had been treated unfairly by the Council and that it failed to provide a timely response to his complaint. Further, it failed to act impartially …
PSOW (Public Services Om…
Local Government
Jun 2021
PSOW-202307706 — Vale of Glamorgan Council
Mrs B complained that Vale of Glamorgan Council failed to provide a response to her Stage 2 complaint, which she made to it on 27 September 2023. The Ombudsman found that the Council had not logged Mrs B’s complaint due to a system failure which incorrectly identified Mrs B’s email …
PSOW (Public Services Om…
Local Government
Jan 2024
PSOW-202308299 — Beaumaris Town Council
Mr A complained that Beaumaris Town Council had failed to respond to a complaint the Ombudsman referred to it in October 2023 regarding a burial plot. Mr A said he had not received any contact from the Town Council. The Ombudsman found that the Town Council had failed to respond …
PSOW (Public Services Om…
Local Government
Feb 2024
PSOW-202304164 — Ceredigion County Council
Mr A complained that Ceredigion County Council (“the Council”) failed to provide a response to his complaint about how it handled his planning application. The Council said it was unable to investigate Mr A’s complaint because it was about the decision to refuse his planning application and therefore it remained …
PSOW (Public Services Om…
Local Government
Nov 2023
PSOW-202306440 — Cardiff Council
Mr H complained that Cardiff Council failed to follow its internal complaint process. A complaint was delivered by hand on 20 July 2023. He made contact via the online form on 8 August seeking an update. Mr H had not received a response. The Ombudsman contacted the Council and was …
PSOW (Public Services Om…
Local Government
Dec 2023
21-016-379 — City of Bradford Metropolitan District Council
Summary: We will not exercise discretion to investigate this complaint about personal injuries suffered by Mrs X after she fell on a public path. This is because it is reasonable to expect her to go to court to determine any liability owed by the Council.
LGO (Local Government & …
Transport And Highways
Feb 2022
21-017-457 — Plymouth City Council
Summary: We will not investigate this complaint about damage to Miss X’s roof tiles caused by a lighting column swaying in a storm. It is reasonable for her to seek a remedy by submitting a claim to the Council’s insurers and, if no liability is accepted, to the courts.
LGO (Local Government & …
Transport And Highways
Mar 2022
21-018-145 — Torbay Council
Summary: We will not investigate Ms B’s complaint that she was injured when using a public toilet. This is because the courts are in the best position to decide personal injury complaints.
LGO (Local Government & …
Environment And Regulation
Mar 2022
21-009-044 — Cheshire East Council
Summary: Mr X complained the Council delayed taking enforcement action in relation to drainage works linked to a development near his property. The Council was at fault for not taking action sooner. The Council has agreed to remedy Mr X’s injustice.
LGO (Local Government & …
Planning
Upheld
Apr 2022
21-000-203 — Allerdale Borough Council
Summary: Mr X complained the Council failed to carry out satisfactory checks and controls on an individual completing building works to the rear of his property. Mr X says the new building’s wall collapsed causing damage to his garden wall.
LGO (Local Government & …
Planning
Not Upheld
May 2022
22-003-014 — Sandwell Metropolitan Borough Council
Summary: We will not investigate this complaint about damage caused to the complainant’s fence. This is because it is reasonable to expect the complainant to go to court to determine any liability owed by the Council.
LGO (Local Government & …
Other Categories
Jun 2022
22-001-793 — Blackpool Borough Council
Summary: We will not investigate Mr X’s complaint the Council has delayed in providing lighting to a rear alley and is treating him as an unreasonable complainant. The Council has explained the action it will take to resolve the matter. It is not treating Mr X as an unreasonable complainant.
LGO (Local Government & …
Transport And Highways
Upheld
Jun 2022
22-004-482 — City of Doncaster Council
Summary: We will not investigate this complaint about financial loss incurred by the complainant after his driveway was damaged by a tree. This is because it is reasonable for the complainant to take his claim to court.
LGO (Local Government & …
Environment And Regulation
Jul 2022
21-018-792 — Cornwall Council
Summary: Mr B complains the Council failed to properly consider a reserved matters planning application and subsequent discharge of condition application for a nearby housing development which he says will allow an unacceptable development to harm both his residential amenity and the local area and cause potential issues of drainage …
LGO (Local Government & …
Planning
Not Upheld
Aug 2022
21-015-882 — Cornwall Council
Summary: Mr X complains the Council failed to properly consider a reserved matters planning application and subsequent discharge of condition application for a nearby housing development which he says will allow an unacceptable development to harm both his residential amenity and the local area. We have found no fault by …
LGO (Local Government & …
Planning
Not Upheld
Aug 2022
21-008-561 — Kirklees Metropolitan Borough Council
Summary: There is no evidence of fault by the Council in how it reached its decision that it cannot take enforcement action to ensure a developer repairs a wall and in how it reached its decision that wall does not pose a risk to highways users.
LGO (Local Government & …
Transport And Highways
Not Upheld
Sep 2022
22-008-869 — Sheffield City Council
Summary: We will not investigate this complaint about how the Council dealt with a planning application. This is because the complainant has not been caused significant injustice as a result of the alleged fault.
LGO (Local Government & …
Planning
Oct 2022
CJINI inspection reports(2)
CQC enforcement actions(6)
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Gloucestershire Hospitals NHS Foundation Trust following an unannounced inspection of urgent and emergency services at Gloucestershire Royal Hospital in December. The inspection was prompted by concerns from people using the …
Gloucestershire Royal Hospital
May 2024
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) told Barts Health NHS Trust that improvements are needed in the diagnostic imaging departments at The Royal London Hospital and Whipps Cross University Hospital. Following a focused inspection in May, CQC found serious concerns including …
The Royal London Hospital and Whipps Cross Univer…
Jul 2021
Warning Notice: Basildon and Thurrock University Hospitals NHS Foundation Trust
The Care Quality Commission raised serious concerns regarding the quality of services at Basildon and Thurrock University Hospitals NHS Foundation Trust. These concerns included a poor care environment in A&E, inadequate arrangements for treating children, and breaches of infection control …
Nov 2009
Warning Notice: Lincolnshire Partnership NHS Foundation Trust
The Care Quality Commission told Lincolnshire Partnership NHS Foundation Trust that it must take action to improve the care of those accessing its specialist mental health and learning disability services. Reports identified areas for improvement including the safety and suitability …
Mar 2011
Warning Notice: Peterborough and Stamford Hospitals NHS Foundation Trust
The Care Quality Commission told Peterborough and Stamford Hospitals NHS Foundation Trust that it must take action to improve services at Peterborough City Hospital. Following a review of compliance, inspectors found the trust was not meeting five essential standards of …
Peterborough City Hospital
Mar 2011
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission demanded that Kent and Medway NHS and Social Care Partnership Trust take action to improve services following a review in November 2010. The review found that two hospitals, William Harvey Hospital in Ashford and a KMPT …
Mar 2011