Quality and safety oversight
Failure to adequately assess, monitor, evaluate, and improve the quality and safety of services, hindering continuous improvement.
Source spread
Where this theme appears
This theme appears across 29 independent accountability sources, so the source mix matters as much as the headline total.
751 inquiry recs
148 PFD reports
583 committee recs
243 HSSIB recs
2000 CQC actions
8 ICIBI recs
6 PPO recs
16 IOPC recs
16 NAO recs
5 PHSO recs
8 IMB recs
2 IMB reports
106 Scottish FAIs
12 detention investigation recs
1368 DHR recs
8 PHSO decisions
35 LGO/SPSO decisions
82 CJINI reports
30 DSA service inquiries
1 Law Commission project
74 CQC enforcement actions
1 EHRC compliance action
2 MNSI reports
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(751)— showing 50 strongest matches
70 — Back paper audits with unplanned inspections
Recommendation: Paper-based audits should be backed up by unplanned inspections and other direct observation of the work under review (para 16.26).
Unknown
69 — Paper procedures must not become divorced from reality
Recommendation: All parties in the industry must ensure that paper-based procedures do not become divorced from reality. This should include senior managers maintaining a direct knowledge of the situation in railway workplaces (para 16.25).
Unknown
68 — Running with AWS isolated where ATP is fitted
Recommendation: GWT, Railtrack and HMRI should consider whether trains with AWS isolated can run normal services where ATP is fitted and operational (para 15.10).
Unknown
66 — Keep ATP fully operational on Great Western lines
Recommendation: ATP should be maintained in a fully operational state on Great Western lines currently fitted, until replaced by an equally effective train protection system (para 15.14).
Unknown
61 — Review of acceptance and approval of new equipment or stock
Recommendation: S&SD together with HMRI and other bodies having responsibility for accepting or approving new equipment or stock should review their procedures with a view to reducing delay and introducing fast-track procedures where possible (para 15.7).
Unknown
60 — Enlarge or re-organise inter-company bodies
Recommendation: Consideration should also be given, for the purpose of the above recommendations, to enlarging or re-organising existing inter-company groups, including considering whether the Railway Group should include ROSCOs and component suppliers (para 16.20).
Unknown
59 — Review of Safety Cases and franchising arrangements
Recommendation: The above recommendation to include review of Safety Cases and franchising arrangements and consideration of action by the Rail Regulator (para 16.22).
Unknown
46 — A single body to set interior safety standards
Recommendation: A single body should be empowered to specify common standards for safety features in the interior of passenger vehicles and to identify and approve types of vehicles and/or operators to which particular standards are to apply (paras 11.6, 16.18).
Unknown
45 — Dates and means for improving existing stock
Recommendation: The review should consider dates and means for the introduction of identified improvements to existing stock (para 11.2, 15.16).
Unknown
44 — Review of internal safety features in passenger vehicles
Recommendation: A review should be carried out by ATOC, with input from all interested bodies, on the ways in which internal safety features may be modified and standardised to provide the best practicable means of emergency exit under accident conditions, including …
Unknown
43 — Long-term review of speed and casualty numbers
Recommendation: HMRI should keep under long-term review the effect of speed on numbers of casualties in rail accidents (para 11.7).
Unknown
42 — Take Dr Murphy's risk analysis into account in any LRM review
Recommendation: Any further review of LRM should take into account Dr Murphy’s risk analysis (para 16.16).
Unknown
41 — Review operation of ARS
Recommendation: Railtrack should review the operation of ARS to consider whether more green signals should be booked ahead of higher speed trains, and generally whether the speed and length of trains is adequately taken into account (para 16.16).
Unknown
40 — More Level 2 and 3 Policy Statements
Recommendation: More Level 2 and 3 Policy Statements should be introduced having due regard to any relevant risk analysis (para 6.16).
Unknown
39 — Review Level 1 Policy Statement
Recommendation: Railtrack should review their Level 1 Policy Statement in the light of any amendment to Condition H11 (para 6.16).
Unknown
38 — Review of Condition H11 of the Track Access Conditions
Recommendation: There should be a review of Condition H11 of the Track Access Conditions which should make clear that no regulating decision is to be made on the basis of protecting commercial interests. Safety and security must be paramount considerations (paras …
Unknown
36 — Review maintenance contracts for what checks are covered
Recommendation: Railtrack should review all maintenance contracts to ensure that all parties are aware of what checks are included and which excluded (paras 3.16, 16.14).
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
33 — Monitor supply of new AWS parts
Recommendation: ATOC and Railtrack should monitor the supply of new AWS parts and components to ensure continued availability on an indefinite basis, including the introduction of improved components (para 15.7).
Unknown
32 — Ownership and rights in AWS equipment
Recommendation: Contractual ownership and other rights in AWS equipment must be clarified and defined (paras 15.7, 16.21).
Unknown
31 — Prevent in-service failure of train-borne safety equipment
Recommendation: Efforts should be concentrated on ensuring that AWS and other train-borne safety equipment does not fail in service through preventable causes. This should include regular replacements of equipment, maintenance of full service records and provision for full traceability of repairable …
Unknown
30 — Improved AWS test box at all depots
Recommendation: An improved AWS test box, capable of detecting faults not revealed by the magnet test, should be provided as standard issue at all maintenance depots (paras 6.11, 9.22, 15.6).
Unknown
29 — Maintenance to check history of reported defects
Recommendation: Maintenance procedures should require checking of the history of reported defects, including repeat faults, and the taking of appropriate action (paras 6.14, 15.6).
Unknown
28 — Flow-chart of the sources of repair work
Recommendation: Maintenance staff should be provided with a flow-chart to show the derivation of all sources of repair work, to include RAVERS (with check on repeat items) and appropriate structure for Request, Repair Book and Maintenance Control items (para 15.16).
Unknown
27 — A-Exam documentation to require ATP reset and self-test
Recommendation: Documentation for the A-Exam should require ATP reset and self-test (para 6.8).
Unknown
26 — Detailed examination checklists for maintenance staff
Recommendation: A current and detailed list of items required to be inspected for each examination should be prepared for and used by maintenance teams (paras 6.8, 15.6).
Unknown
25 — GWT to monitor maintenance staff workload
Recommendation: GWT should regularly monitor the workload of all maintenance staff (para 15.6).
Unknown
24 — GWT records of maintenance staff competencies
Recommendation: GWT should maintain full records of competencies for all maintenance staff as required by job descriptions and safety responsibility statements (paras 6.8, 15.6).
Unknown
21 — Controllers' posts designated safety-critical
Recommendation: Controllers’ posts in Railtrack and TOCs should be designated as “safety-critical” as defined in the Railways (Safety Critical Works) Regulations 1994 (para 9.15).
Unknown
18 — Failure to provide fault reporting means a disciplinary offence
Recommendation: Failure to provide forms, defect repair books or other means of reporting faults should be regarded as a disciplinary offence (para 16.11).
Unknown
17 — Simpler fault reporting procedures
Recommendation: Fault reporting procedures should be reviewed and made as simple and convenient to use as practically possible. They should include provision for an acknowledgement and an explanation if relevant (para 16.11).
Unknown
14 — National procedures on failure of train-borne safety equipment
Recommendation: Clear procedures for steps to be taken on failure of any train-borne safety equipment should apply nationally, subject only to such company variation as is fully justified (para 15.11).
Unknown
13 — AWS is vital to the continued running of the train
Recommendation: AWS is to be regarded as vital to the continued running of the train (para 15.11).
Unknown
12 — Designate train-borne safety equipment as vital or not
Recommendation: All train-borne safety equipment should be clearly designated as to whether or not it is vital to the continued running of the train (para 15.11).
Unknown
11 — Avoid using several documents for one operational issue
Recommendation: The use of more than one document (whether Rules, Group Standards or otherwise) to cover a single operational issue should be avoided, save where proper reasons exist for use of multiple sources (para 15.9).
Unknown
10 — Rules and Group Standards clear and unambiguous
Recommendation: Railtrack must ensure that Rules and Group Standards applicable to operators, including drivers, are clear and unambiguous. In particular, Railtrack should urgently complete the review of operating Rules to ensure they are workable in the privatised, fragmented industry (para 16.6).
Unknown
9 — Review of drivers' working hours
Recommendation: Current Rules governing drivers’ permitted daily and weekly working hours should be reviewed in the light of current research into human behaviour (para 5.9).
Unknown
8 — Monitor driver transfers and numbers trained
Recommendation: Railtrack and ATOC should monitor the transfer of drivers between operators and the numbers of drivers trained by each TOC and consider whether there are any safety implications involved (paras 5.5, 16.5).
Unknown
7 — National qualification and accreditation system for drivers
Recommendation: Railtrack together with ATOC should establish a national qualification and accreditation system for drivers including centrally held records to be available to the current employer (paras 5.5, 16.5).
Unknown
6 — Encourage drivers to report faults
Recommendation: Drivers should be encouraged to report all actual or suspected faults, whether through formal fault reporting procedures or through CIRAS (paras 14.26, 16.4).
Unknown
5 — Testing of driver competence and knowledge of the Rules
Recommendation: Testing of driver competence and knowledge of Rules should be extended to cover application of the Rules to practical situations, including all abnormal driving situations permitted by the Rules (para 16.4).
Unknown
4 — Driver training in abnormal situations
Recommendation: Driver training should include driving in abnormal situations permitted by the Rules and specifically driving with AWS isolated to the extent so permitted, including the use of simulators (para 16.4).
Unknown
3 — Simulators for driver training
Recommendation: Simulators should be introduced for driver training and for the observance of driver behaviour (para 16.3).
Unknown
2 — Evidence from CIRAS and on-train data recorders
Recommendation: Evidence should include that to be provided by CIRAS and from On-Train Data Recorders used to monitor driver behaviour. ASLEF in particular should give their full support to such an initiative (paras 14.23, 14.25, 15.15, 16.3).
Unknown
1 — Co-operate on research into driver behaviour
Recommendation: All parties in the rail industry should co-operate in the collection of evidence to support reliable research into human behaviour studies relating to driver performance. Railtrack should co-ordinate this work and TOCs incorporate the results into training programmes (paras 1.25, …
Unknown
23 — General Nursing Council inspection
Recommendation: The General Nursing Council should be invited to inspect Whittingham Hospital.
Unknown
17 — Professional Executive and therapeutic teams
Recommendation: The Group Secretary, the Chairman of the Medical Executive Committee and the Chief Nursing Officer, with other appropriate professional heads, should constitute a Professional Executive with delegated authority for day-to-day management of the hospital. They should maintain close liaison with …
Unknown
16 — Medical Executive Committee
Recommendation: The senior medical staff with clinical sessions at the hospital, together with representatives of other medical staff, should constitute a Medical Executive Committee, electing a Chairman whose appointment should be subject to yearly renewal. The Chief Nursing Officer and other …
Unknown
12 — Review of services needed at Whittingham
Recommendation: The new Hospital Management Committee should carry out a thorough review of the reorganisation of services needed at Whittingham Hospital.
Unknown
Prevention of Future Deaths reports(148)— showing 50 strongest matches
Walter Gordon Powley
Concerns: Uncovered, high-temperature radiator pipes and valves exceeded safety guidance, posing a burn risk. The room lacked a physical risk assessment, and regulatory body inspections had not identified these issues.
Response (CQC): • The CQC stated it would share the report's findings within its organisation. • The CQC is piloting a new methodology that will assess services against five domains, including a … (AI summary)
Response (Health Safety Executive): • HSE stated its intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting of the GB Social Care Partners Forum. • … (AI summary)
Response (RNHA): • The Association regularly advises its members on their responsibilities under the Health & Safety at Work Act. • The Association specifically advises members on the need to ensure pipes … (AI summary)
Responded
Kathleen Rosemary Dixon
Concerns: The coroner noted the recurrence of similar circumstances in multiple previous inquests involving the Trust and recommended an independent assessment.
Response (Department of Health): • The Care Quality Commission (CQC) issued two warning notices to the Trust in October 2013 concerning the care and welfare of service users and staffing. • The CQC published … (AI summary)
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise an acutely unwell resident or act on low blood pressure, exacerbated by a lack of ongoing training. Managers also did not effectively investigate incidents and provided inaccurate reports to the Care Quality Commission.
Overdue
Derrick Rivers
Concerns: The coroner identified inadequacies in the care home's drug administration policy and audit processes, which were not fully noted by the Local Authority or CQC during inspections. Concerns were also raised about management's awareness of staff not following protocols and delayed action on recommendations.
Overdue
Clive Clinton
Concerns: The coroner noted apparent failings in the care home's complaints procedure, which allowed staff to withhold concerns from senior management. There was also a lack of information for families on how to direct complaints to a more senior level within the organisation.
Overdue
Peter White
Concerns: The coroner noted concerns regarding the hospital's Early Warning Observation Chart system, specifically its incorrect completion, ignored triggers, and lack of review by qualified staff. There is also no regular audit system to ensure proper use of the charts.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: The report notes the absence of national governance, a lead, and disease-specific benchmarking for autologous stem cell transplant. Unreleased international trial results prevent clinicians from knowing normal recovery times, potentially affecting optimal care for children.
Response (NHS England): • NHS England will issue a Specialised Services Circular to commissioning teams and providers, restating requirements for transplant providers. • NHS England will review service specifications for paediatric bone marrow … (AI summary)
Responded
Edwin Thompson
Concerns: The coroner raised concerns about the lack of clear directives for care staff on promptly seeking medical advice for residents' pain, particularly cardiac. Further issues included the need for formalised, regular staff training and improved accuracy and management oversight of record-keeping.
Overdue
Huseyin Erdogan
Concerns: The coroner noted a lack of evidence that steps outlined in two action plans, created in response to Mr. Erdogan's death, had been completed by the stated deadlines prior to the inquest. This delay in implementation raises concerns about preventing future deaths.
Overdue
Maurice Cowling
Concerns: The coroner identified a potential inadequacy of resources within the Trust area to manage recognised complications arising during or after certain medical procedures, following three instances.
Response (Northern Lincolnshire Goole NHS Trust): • The Trust completed a patient safety review of the three cases. • For one case, a Serious Untoward Incident report was completed, and all associated recommendations were implemented. • … (AI summary)
Responded
Kathleen Neville
Concerns: The coroner noted the absence of a Medication Reconciliation policy at University Hospital of Wales, which made it difficult to identify medication omissions. Concerns were raised that other Health Boards in Wales might also lack this policy, potentially risking future deaths.
Overdue
Amanda Ellams
Concerns: The coroner noted poor medical and nursing note-keeping at Alexandra Hospital, including a lack of full medical history pre-operatively and discharge despite low oxygen levels. There were also unanswered out-of-hours calls to the District Nursing team.
Response (Response Alexandra Hospital): • The hospital established a new documentation standards audit in June 2015 and scheduled training sessions on documentation and patient care pathways for clinical staff. • The consultant surgeon committed … (AI summary)
Overdue
Adrian Smith
Concerns: Instructions from Queen Elizabeth Hospital for an MRI scan were not followed by Good Hope Hospital staff, highlighting a need for systems to ensure specialist advice is adhered to.
Response: • The Trust stated that consultant radiologists will now discuss cases with a peer consultant radiologist and the patient's consultant before declining a requested radiological investigation. • The Trust indicated … (AI summary)
Overdue
Angela Brealey
Concerns: The coroner identified concerns regarding the Trust's processes for handling and recording third-party information, particularly regarding confidentiality. There was also minimal multi-disciplinary team involvement in patient care and the serious incident review process did not pick up all concerns.
Response (South Staffordshire and Shropshire Healthcare NHS Trust): • The Trust has implemented a clear policy and process for receiving and storing third-party information in RiO. • The Serious Incident Review Process has been reviewed and amended, with … (AI summary)
Overdue
Harry Gill
Concerns: The coroner raises concerns about the robustness of the NHS 111 vomiting pathway, noting that only one out of four calls received an appropriate response.
Response (NHS England): • NHS Pathways concluded a review of its vomiting questions and enhanced their content. • The vomiting questions were amended to include more specific prompts for coffee ground vomit, blood, … (AI summary)
Responded
Martyn Watkins
Concerns: The coroner recommended a review of the care and treatment provided by the Trust, particularly on Aspen Ward, following jury findings and internal reports. The CQC should ensure identified deficiencies are addressed and safe care arrangements are in place.
Response (CQC): • The CQC conducted an inspection of Aspen Ward between 16 and 27 May 2016, noting the Trust had implemented changes to manage future risks. • The CQC exercised statutory … (AI summary)
Overdue
Norman Beard
Concerns: The coroner identified poor management, a lack of clear policies, and staff and resource shortages due to financial difficulties. Concerns also included delayed referrals for a resident's pressure ulcers and weight loss, and insufficient follow-up on medical advice.
Overdue
Barry Thompson
Concerns: The coroner identified non-compliance with national sepsis protocols, including delayed doctor review and antibiotic administration. Concerns also included inadequate monitoring and management of diabetes, as well as unreliable record-keeping and poor information sharing between hospital departments.
Overdue
Helen Millard
Concerns: The coroner highlighted an incongruity in the 'traffic light' classification of ligature points in psychiatric facilities, where ligatures one metre or less are 'amber' despite posing an extreme risk. It was suggested all such points should be classified as 'red' for urgent elimination.
Overdue
Doreen Willis
Concerns: The coroner asked the CQC to consider recommendations from a Root Cause Analysis Report during future care home inspections and to review the nature of their inspections based on identified learning points.
Response (Torbay and South Devon NHS Trust): • The Trust provided a summary of key learning outcomes identified from a multi-agency review. • The summary detailed recommendations for care homes regarding medicines management policies, staff responsibilities, and … (AI summary)
Responded
Sam Crick
Concerns: The coroner noted that neuroradiological reviews missed obvious signs of rising intracranial pressure on CT scans, and a critical report was not available for a key neurosurgeon consultation. There was also a lack of a Serious Incident Report for a preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): • A Significant Incident (SI) notification was completed, and an SI was declared on 31 August 2017, with an investigation ongoing. • The Trust developed a 'Learning Deaths' policy and … (AI summary)
Response (CQC): • The CQC contacted Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) to request confirmation and evidence of actions taken and planned in response to the PFD report. • … (AI summary)
Response (NHS England): • NHS England stated it would work with the Society of British Neurological Surgeons and the Royal College of Emergency Medicine to produce and distribute national guidance on the use … (AI summary)
Responded
David Lindsey
Concerns: The coroner noted family contentions regarding the trust's adherence to NICE guidelines and its own policies for cancer screening, referrals, diagnosis, and treatment.
Overdue
Brian Betterton
Concerns: The coroner highlighted the ineffectiveness of product recalls for items installed by a third party in domestic properties, noting the absence of a requirement for professional purchasers to track end users or inform manufacturers.
Response (Department for Business Energy Industrial Strategy): • The Department established a Working Group on Product Recalls and Safety. • It supported the development of a new BSI code of practice on corrective action and recalls, into … (AI summary)
Responded
Sarah Kiff
Concerns: The coroner identified that GPs did not follow cancer referral guidance, and noted poor medical record keeping, communication, and inadequate processes for reviewing test results. Concerns also included a lack of continuity of care and reluctance among some doctors to perform internal examinations.
Response (Stonefield Street Surgery): • The practice implemented new protocols for high vaginal swabs (HVS) and internal referrals, including a mechanism for patients to be referred to a preferred clinician for intimate examinations. • … (AI summary)
Responded
Elaine Bradbrook
Concerns: The coroner raised concerns regarding the failure to escalate and act on a patient's deteriorating condition, the lack of clinical review and risk reduction during transfer, and the trust's subsequent lack of internal investigation or learning opportunities.
Response (United Lincolnshire Hospitals NHS Trust): • The Trust stated it had made significant improvements to its Serious Incident (SI) process in the last 12 months, incorporating training. • An Interim Director of Governance was leading … (AI summary)
Responded
David Sketchley
Concerns: The report identifies concerns regarding the quality of the BUPA investigation, which did not conclude on supervision levels or commode suitability. It also notes an absence of evidence that BUPA's practice reflects care service standards for commode assessments.
Response: • The Medicines and Healthcare products Regulatory Agency (MHRA) stated that commodes are not regulated as medical devices in the UK. • The MHRA will continue to pass reports of … (AI summary)
Overdue
Neville Welton
Concerns: The coroner identified delays by the Health Board in concluding its investigation and formulating an Action Plan for Mr Welton's death, with agreed implementation timescales not met. Concerns were also raised about the Health Board's general timeframes for Serious Incident Reviews and subsequent Action Plans.
Response: • The Health Board is revising its model for serious incident investigations to support divisions and ensure action plans are developed earlier in the process, with formal commencement in September … (AI summary)
Overdue
Lewis Colgan
Concerns: The coroner identified gaps in the supervision of care coordinators. Concerns also arose regarding maintaining continuity of care during staff absences and the lack of robust processes for managing Care Programme Approach meetings.
Overdue
Ester Wood
Concerns: The coroner raises concerns about persistent ambulance delays, emergency department admission delays, resource availability, and patient flow issues. These recurring problems continue to place patients' lives at risk despite previous reports.
Overdue
Margaret Evans
Concerns: The coroner noted ongoing issues with ambulance delays, emergency department admissions, resource availability, and patient flow. These persistent problems continue to place patients' lives at risk, despite having been reported on previously.
Overdue
Ruth Whitmore
Concerns: The coroner noted a nurse was unaware of her responsibility for the ward and for initiating an immediate investigation, as this was not clearly communicated at handover. Concerns were also raised about the robustness of the initial investigation, which lacked staff interviews and detailed analysis of events.
Overdue
Sophie Bennett
Concerns: Inadequate governance was identified at Lancaster Lodge, including the lack of a registered manager, insufficient trained staff, and poor controls on resident documentation. The coroner also noted grossly inadequate leadership and oversight by the Board, impacting employment and communication procedures.
Overdue
Tom Cribley
Concerns: The coroner raised concerns about the lack of a systematic and monitored training programme for clinical staff in sepsis identification and treatment. This is crucial given recurring issues identified in documentation, timely escalation of patient deterioration, and handovers.
Overdue
Jean Cutler
Concerns: The coroner identifies an inconsistent approach to falls prevention for wheelchair users inside the nursing home, with an inadequate reliance on staff intervention. Concerns also relate to the insufficient post-incident investigation and incomplete falls risk assessment documents.
Response (Cole Valley Nursing Home): • The previous manager was removed, and a consultant advisor was engaged to support improvements and recruit a new permanent manager. • New comprehensive Falls Risk Assessments (FRAs) for all … (AI summary)
Responded
Kathleen Smith
Concerns: Staff lacked sufficient training in first aid, assisting choking residents, and preparing special dietary foods. There was also inadequate management oversight regarding staff deployment for residents at risk of choking.
Response (Coed Duon Care Home): • Several staff members have completed first aid courses, ensuring at least one qualified First Aider is on duty. • All current staff have been trained in basic dysphagia awareness, … (AI summary)
Responded
Daniel Williams
Concerns: The coroner noted concerns regarding a vulnerable patient's transfer to a ward where fundamental nursing care was later found deficient, and the C-diff investigation process did not extend to prior wards where care failings occurred.
Response (Guys and St Thomas NHS Trust): • The Trust reviewed and updated its education and training programme for nurses on the GI unit, including wound care and collaboration with specialist nurses. • A specialised induction programme … (AI summary)
Responded
Ben Haddon-Cave
Concerns: The coroner noted inadequate fence inspections due to obscured views and alternative access not being used. Concerns were also raised regarding a flawed dual reporting system that prevented identification of inspection failures, and an insufficient internal investigation by Network Rail.
Response (Network Rail): • Network Rail implemented a revised Boundary Fencing Inspection Standard in April 2019, which mandates electronic records and includes a new process for recording and reviewing non-tactile inspections. • A … (AI summary)
Responded
Pamela Evans
Concerns: The coroner identified an inconsistent understanding among nursing staff about when to escalate to the critical care outreach team, as well as limited powers for outreach nurses to order urgent diagnostics. Inaccurate NEWS score recording was also noted, and the Trust's investigation failed to detect these issues.
Response (Bedford Hospital NHS Trust): • The Trust undertook direct clinical training for all nursing staff on NEWS2 escalation and launched a new NEWS score sticker for patient notes. • The Trust undertook substantial work … (AI summary)
Responded
Evelyn Swift
Concerns: The Beechdale Medical Group lacked safe procedures for patient triage, home visit allocation, and documentation of patient calls and home visit notes. Concerns were also raised about insufficient clinical capacity and the absence of a process to review significant events for learning.
Overdue
Gillian McKinlay
Concerns: Concerns included a lack of clear clinical responsibility for long-stay A&E patients, failure to conduct mandated clinical reviews based on EWS scores, and a lack of escalation by nursing staff. The Trust's own investigation was also deemed inadequate.
Overdue
Frank Medley
Concerns: The coroner identified an ineffectual system for detecting adverse outcomes in patients transferred to tertiary centres. Concerns were also raised about a seriously deficient internal case review, and failures in sepsis management and expediting urgent scans.
Response (Royal Blackburn Teaching Hospital): • A core group was established to oversee the action plan's implementation, and a weekly complex case coordination meeting was introduced to integrate legal services. • New MRI systems were … (AI summary)
Responded
Elizabeth Robinson
Concerns: The coroner noted insufficient nursing staff levels impacted patient supervision and nurses' ability to take full breaks. Furthermore, front-line nursing staff had not received the findings of the internal investigation into the patient's death.
Response (Aneurin Bevan University Health Board): • The Health Board established a Health Care Support Worker pool in September 2020 and employed an additional 145 WTE HCSWs to support enhanced care. • A full acuity audit … (AI summary)
Responded
Rachel Johnston
Concerns: The coroner noted Pirton Grange lacked a robust policy for investigating staff misconduct, including imposing suspensions and reporting to the NMC. Following a death, initial investigation and reporting of nurse conduct to the NMC were inadequate and delayed.
Response (Holmleigh Care Homes Ltd): • The Home engaged a solicitor's firm to provide independent oversight and advice on HR matters, investigations, disciplinary actions, and professional body reporting. • The Home appointed a new Registered … (AI summary)
Overdue
Pauline Brumfitt
Concerns: The care home did not apply its falls risk assessment and prevention policies, missing opportunities to reassess the resident's risks after three falls. There was a lack of timely reporting to regulatory bodies and delayed commencement of staff supervision regarding falls prevention.
Response (Anchor Hanover Group): • Disciplinary proceedings were initiated against staff involved in reporting failures, resulting in a manager's resignation and a Disclosure and Barring Service referral. • A detailed individual falls tracker was … (AI summary)
Overdue
Kyle Hurst
Concerns: The coroner identified delays in adopting a proposed N-Acetylcysteine administration protocol and in implementing diagnostic results procedures by a stated deadline. The report raises concerns about the Health Board's timely implementation of changes.
Response (BCUHB): • The Health Board stated it would take an executive decision to approve the SNAP protocol by 31 January 2022, with immediate implementation. • A new Procedure for the Communication … (AI summary)
Responded
Susan Merton
Concerns: The Health Board did not review an Action Plan as scheduled, which is a recurring issue where the Board fails to complete its own actions within set timeframes. The coroner noted that this lack of follow-through with recommendations puts lives at risk.
Response (BCUHB): • The Health Board implemented a new serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. • … (AI summary)
Overdue
Philip Ellis
Concerns: The deceased was able to leave the service premises unsupervised and obtain drugs, breaching the service's own rules. Additionally, a serious incident review into the supervision failures had not been undertaken by Free the Way.
Response (Free the Way): • Clients re-entering treatment will be escorted to their homes if required, and their property will be searched by a member of staff. • Clients entering treatment will not be … (AI summary)
Responded
Emma Burbury
Concerns: The coroner noted a missed opportunity to provide care for a dual diagnosis patient and identified gaps in inter-agency communication, including reciprocal record access. Concerns were also raised about patients being easily discharged without assertive engagement or referral to other agencies.
Response (Cornwall Partnership): • The Trust is planning workshops to support staff in embedding the principles of the Dual Diagnosis Strategy into clinical practice. • The Trust is working on a Shared Care … (AI summary)
Response (NHS Kernow Clinical Commissioning Group): • A task and finish group is developing a revised Data Protection Impact Assessment (DPIA) to enhance information sharing and address reciprocal access to clinical records between organisations. • Existing … (AI summary)
Responded
Darrell Devlin
Concerns: The coroner raised concerns that reliance on remote contacts and lack of drug testing made accurate assessment and support of clients difficult, increasing risks from excessive dosage or polydrug exposure. This highlights a need for more effective supervision.
Response (Humankinds): • Humankind's mobilisation strategy includes reviewing all service users at a face-to-face appointment. • The strategy commits to drug testing all service users via urinalysis who have not been tested … (AI summary)
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust developed guidance for staff to review service users' risk factors, medication stability, and engagement. • The service issued guidance advising that all first appointments should be face-to-face … (AI summary)
Responded
Rebecca Begg
Concerns: The coroner identified insufficient monitoring of care plan compliance, a lack of robust incident reviews, and support workers not being included in client progress meetings. Concerns were also raised regarding a lack of clarity on procedures for serious self-harm incidents and the absence of a formal escalation process with the mental health trust.
Response (Heathcotes Group): • The organisation confirmed that full incident reviews are implemented, with the Registered Manager reviewing and documenting follow-up actions. • Observation care plans have been formulated for each individual, including … (AI summary)
Overdue
Select committee recommendations(583)— showing 50 strongest matches
#38 —
Recommendation: The OfS should make the necessary adjustments to its framework to comply with international standards and respect the DQB’s need to make impartial assessments of quality and standards, with a view to allowing the QAA or another arms-length body to …
Response attribution not verified
#37 —
Recommendation: The OfS should work urgently to align its framework for quality with international standards, including by publishing all assessment reports and including students on assessment teams. The OfS should explore the extent to which its own assessment of risks as …
Response attribution not verified
#24 —
Recommendation: The Government and the OfS should clarify whether there is any strategic oversight of the higher education sector’s long-term financial stability, including whether to encourage mergers and consolidation. If no such function exists, they should consider whether it is necessary …
Response attribution not verified
#23 —
Recommendation: HEFCE, the OfS’ predecessor, had the ability to facilitate and broker mergers and consolidations of providers where there were difficulties, facilitating planned solutions rather than disorderly exits. It is not clear whether either the OfS or the Government has taken …
Response attribution not verified
#20 —
Recommendation: The OfS should prioritise holding discussions with providers more regularly about their financial situation, in particular those that are not considered high-risk.
Response attribution not verified
#19 —
Recommendation: The OfS’ targeted approach can mean it communicates little with institutions whose financial data appears healthy. This limits the regulator’s knowledge of providers that are not in financial difficulties, makes it harder to identify risks that are not evident in …
Response attribution not verified
#15 —
Recommendation: Given the scale of these challenges, we were surprised by the OfS Chair’s assertion that the sector’s finances are “in good shape”. This is not an assessment that we or most of our witnesses share. In our view, this remark …
Response attribution not verified
#2 —
Recommendation: In particular, the OfS does not appear to have prioritised its duties to protect the institutional autonomy of providers or to have regard to the principles of best regulatory practice, causing friction between the regulator and the sector.
Response attribution not verified
#1 —
Recommendation: It is claimed that the OfS’ statutory duties are clearly set out in legislation, but they have been applied inconsistently and unequally. Given that the OfS’ duties are “have regard to” duties, with no sense of priorities, the regulator, and …
Response attribution not verified
#148 —
Recommendation: The National Infrastructure Commission, in its review of the planning system for infrastructure also called for a more strategic approach to environmental mitigation. There is a not always a consistent approach to mitigation, nor effective monitoring and enforcement, meaning that …
Response attribution not verified
#28 —
Recommendation: NHS England should designate a senior, named person with responsibility for the homecare system. That person should be given sufficient powers and resources to discharge that responsibility. Responsibilities should include: (a) Setting clear national KPIs for organisations commissioning and providing …
Response attribution not verified
#21 —
Recommendation: The Secretary of State for Health and Social Care should instruct the CQC to conduct a thematic review of homecare medicines services. (Paragraph 86) State of the market
Response attribution not verified
#20 —
Recommendation: The Secretary of State should review the regulatory regime for homecare medicines services, considering in particular the lack of enforcement action taken by the CQC against homecare providers where avoidable harm has occurred. The review should identify a lead regulator …
Response attribution not verified
#19 —
Recommendation: The regulatory model for homecare is failing to ensure the safety and quality of patient care. The regulators appear to have a limited understanding of the sector and there appears to be no appetite to find more information. Enforcement action …
Response attribution not verified
#16 —
Recommendation: Though there is substantial variation, in many cases, those procuring and recommending homecare services appear ill-equipped to do so. In some cases, expertise is missing; in others, there is insufficient information. Given this, and the clear commercial incentives for manufacturers …
Response attribution not verified
#13 —
Recommendation: The Chief Pharmaceutical Officer for England should ensure that the KPI data is published in a consistent, standardised form which is sufficiently specific and regular to ensure meaningful public scrutiny. (Paragraph 58) Purchasing
Response attribution not verified
#12 —
Recommendation: Publication of performance data and greater inclusion of patient perspectives in that data are welcome. However, there is a risk that the performance data could be published in such a diluted form that it becomes meaningless. How frequently the data …
Response attribution not verified
#9 —
Recommendation: NHS England must identify how many patients have become unwell or have been harmed because of a failure in homecare services. They should ensure that this information is published and shared with relevant parties. It should also form part of …
Response attribution not verified
#8 —
Recommendation: No one—not the Government, not NHS England, not patient groups, not regulators, knows how often, nor how seriously patients suffer harm from service failures in homecare. This indicates a significant failure of oversight and hinders the ability of NHS England …
Response attribution not verified
#14 —
Recommendation: The National Audit Office (NAO) criticised previous delivery failures in cyber security in 2019, finding that the Government risked making the same mistakes with its subsequent National Cyber Strategy. The Government’s Performance Framework for the 2022 NCS appears to be …
Response attribution not verified
#21 —
Recommendation: The Government should accelerate its collaboration with industry to develop a ‘battery health standard’ that is objective and reliable.
Response attribution not verified
#51 —
Recommendation: The relationship between regulators and those they regulate needs to be finely balanced, as the danger of regulatory capture is ever present. However, there must be an open and frank dialogue between regulators and those they regulate, providing clarity for …
Response attribution not verified
#6 —
Recommendation: The evidence we received highlighted the value of regulatory independence. Independence enables regulators to act flexibly in response to emerging challenges and allows them the freedom to speak truth to power. It also supports business confidence and investment by separating …
Response attribution not verified
#5 —
Recommendation: The Government should undertake similar reviews of the duties of all regulators when they are reviewed as part of the Public Bodies Review Programme. These reviews should aim to streamline the duties and objectives of regulators and provide the greatest …
Response attribution not verified
#4 —
Recommendation: It is welcome that the Government is actively considering these issues as part of its Smarter Regulation programme and plans to review the duties of each of the economic regulators. In doing so, it should focus their objectives on their …
Response attribution not verified
#49 —
Recommendation: The Government should build on initiatives from the National Grid Energy System Operator like the Demand Flexibility Service, expanding them and making them permanent. This should involve a robust programme of consumer research to ensure people who provide flexibility are …
Response attribution not verified
#43 —
Recommendation: We have heard that obtaining planning permission for energy storage facilities can be difficult and add significantly to timelines. It is not clear that the planning system has distinct guidance for energy storage facilities as opposed to energy generation. There …
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
#10 —
Recommendation: We also recommend that an insolvency SAR should be triggered earlier if key provisions of a more robust Turnaround Oversight Regime are not adhered to, such as a direction to inject new equity, particularly if this results in shareholders abandoning …
#4 —
Recommendation: Those who are truly in control of a water company should be subject to appropriate checks and oversight. Future regulation must recognise the control that creditors can exert over a company facing insolvency and ensure that Ultimate Controller safeguards apply …
#3 —
Recommendation: Ultimate Controller undertakings protect regulated entities from poor or unscrupulous behaviour by the company owners, usually shareholders. This will likely underpin any future powers to block ownership transfers if the government accepts this IWC proposal. However, when a company is …
#2 —
Recommendation: Given the longstanding and compounding issues that some water companies are facing in the sector, a future supervisory water regulator must have the powers to intervene sooner when companies are beginning to demonstrate a lack of financial resilience or persistent …
#1 —
Recommendation: Many water companies are struggling to turn around their performance without stronger intervention. Thames Water has demonstrated that Ofwat’s turnaround regime is imposed too late and has limited capacity to tackle vicious cycles of penalty and failure. The IWC’s report …
#8 —
Recommendation: It is clear that the FCA has modified its proposals on announcing its enforcement investigations significantly between its first and second consultations. The FCA’s revised proposals demonstrate a clearer commitment to safeguarding both market integrity and the legitimate interests of …
#6 —
Recommendation: The original proposal giving firms 24 hours’ notice of the announcement of an investigation was insufficient given the amount of activity required to prepare for such an announcement. The revised proposal, to give firms 10 business days to make representations, …
#3 —
Recommendation: The FCA should ensure that consultations are properly registered on the Regulatory Initiatives Grid. It should also review its internal processes to ensure that earlier engagement with the sector is carried out when appropriate .
#39 —
Recommendation: The Government should ensure that a new independent single register of interpreters is established which ensures a high standard of vetting and entry criteria, so that highly skilled interpreters have access to work across the criminal justice system. (Paragraph 175) …
Response attribution not verified
#13 —
Recommendation: As part of the new quality assurance process contract, the MOJ should ensure that assessments regularly take place in ‘closed’ settings such as family courts. Assessment processes should be amended to enable assessors to effectively judge the quality of whispered …
Response attribution not verified
#12 —
Recommendation: The current assessment process cannot capture interpreting in key instances of court interpreting, such as closed courts and whispered interpreting. This means that assessment data may miss interpreter errors in certain court settings. It also means that assessment data used …
Response attribution not verified
#11 —
Recommendation: The nature of interpreting means it is extremely challenging for non-interpreters to identify poor quality interpreting. As such, a robust quality assurance system is of paramount importance for interpreting in the courts. (Paragraph 71) Quality assurance
Response attribution not verified
#5 —
Recommendation: As such, we are concerned that the current provision of interpreting services in the courts is not acceptable and presents a significant risk to the administration of justice.
Response attribution not verified
#1 —
Recommendation: While interpreting services may affect a small proportion of the cases seen in courts, it is essential that in those cases justice is administered effectively.
Response attribution not verified
#59 —
Recommendation: The government must give the AISI a statutory duty to inform the authorities, including the new AI oversight body, of potential risks posed by AI models and systems. This should include a duty to advise the oversight body of the …
#58 —
Recommendation: Developers of powerful AI models must be required to submit new models (and new versions of existing models) to AISI for review, evaluation, and testing. They must also provide technical specifications, including model properties, training data and process, intended use, …
#57 —
Recommendation: The government should place AISI on a statutory basis. AISI should have the power to review new and revised powerful AI models. It should also have a duty to assess, publish findings pre-release, and issue preliminary ‘warning’ statements associated with …
#56 —
Recommendation: The new oversight body should: a. have the power to facilitate co-ordination with other national regulators in relation to monitoring, investigation and enforcement, knowledge sharing, and capacity building b. make regular reports on its activities to Parliament, identifying opportunities to …
#139 —
Recommendation: An example of the burdens that firms can incur responding to consumer focussed regulation is the need for firms to demonstrate that their wholesale activities are outside of the scope of consumer regulation. Cuan Coulter told us that: “… our …
Response attribution not verified
#138 —
Recommendation: Aon told us that the application of consumer protections to wholesale markets is unnecessary and burdensome given the sophistication of the counterparties in such markets: “… in wholesale markets—such as the London Market—customers are sophisticated corporate entities with teams of …
Response attribution not verified
#137 —
Recommendation: Witnesses suggested that consumer protection, intended to manage these asymmetries between consumers and firms, has increasingly applied to wholesale markets. Sir Howard Davies told us: “Yes, there has been a bit of a blurring of the line between wholesale and …
Response attribution not verified
HSSIB safety recommendations(243)— showing 50 strongest matches
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and oversight roles and responsibilities specification in oversight processes to highlight where further support and resource is needed to meet the expectations under PSIRF.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and oversight roles and responsibilities specification to assess organisational support and where further resource is needed for PSIRF implementation.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Use the patient safety incident response standards and national guidance on engaging and involving those affected to assess practice and identify where additional resource and support is needed.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Develop an accreditation process to assure the quality of PSIRF training.
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation manage and oversee configuration changes to EPR systems to ensure they are appropriate, safe and successful?
Learning Prompt
Patient care in temporary care environments
Does your organisation gather information about the use of temporary care environments including: the patient cohorts using temporary care environments a description of the temporary care environment how long patients have been in a temporary care environment incidents that have …
Learning Prompt
Patient care in temporary care environments
NHS regional and national organisations can improve patient safety by enhancing understanding of the use of temporary care environments across all hospital settings. This may include agreeing definitions of temporary care environments and enhanced information gathering on their use and …
Safety Observation
Insulin: supporting safe administration in inpatient settings
Professional regulators and royal colleges can improve patient safety by reviewing this report and disseminating appropriate communications to their registrants and members in relation to understanding their expectations in providing safe diabetes care.
Safety Observation
Insulin: supporting safe administration in inpatient settings
HSSIB recommends that the Care Quality Commission assesses how it can use data from the Diabetes Care Accreditation Programme and the new National Diabetes Audit for Inpatient Care as part of its regulatory activity. This is to ensure that known …
Safety Recommendation
Insulin: supporting safe administration in inpatient settings
HSSIB recommends that NHS England/Department of Health and Social Care sets out the expectations and responsibilities of NHS trusts, integrated care boards and NHS England for the oversight and assurance of inpatient diabetes care. This should support organisations to implement …
Safety Recommendation
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance …
Safety Recommendation
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
Commercial manufacturers and NHS organisations can improve patient safety by contributing to and engaging with ePRaSE (ePrescribing Risk and Safety Evaluation) processes to support ongoing improvement and optimisation of electronic prescribing and medicines administration (ePMA) functionality across the NHS.
Safety Observation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that the Care Quality Commission reviews the sector-level assessment frameworks it is developing to include assurance of ongoing compliance with the digital clinical safety standard (DCB0160) for electronic prescribing and medicines administration (ePMA) software. This will help to …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that NHS England/Department of Health and Social Care develops an external assurance framework for information standards notices relating to electronic prescribing and medicines administration (ePMA). This is to reduce unwarranted variation and improve patient safety through expert-led assurance …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that NHS England/Department of Health and Social Care establishes a national framework for core electronic prescribing and medicines administration (ePMA) safety. This will provide a clear set of minimum patient safety requirements, helping to reduce unwarranted variation in …
Safety Recommendation
Medication not given: administration of time critical medication in the emergency department
NHS trusts can improve patient safety by using the information contained in the information pack for the Royal College of Emergency Medicine’s Quality Improvement Programme on time critical medications to assess their preparedness and make local improvements in identifying, prescribing, …
Safety Observation
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you identify and facilitate proactive communication with a point of contact at the integrated care board with oversight of the care pathway?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure that risks to the care pathway are identified and mitigated to as low as reasonably practicable across different organisations?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure concerns about the care pathway are escalated and acted on by senior and executive leadership teams across different organisations and the integrated care board?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure shared governance forums are appropriately established and resourced, and are effective?
Learning Prompt
Transition from child and adolescent mental health services to adult mental health services
It is recommended that the Care Quality Commission (CQC) extends the remit of its inspections to ensure that the whole care pathway, from child and adolescent mental health services to adult mental health services, is examined.
Safety Recommendation
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that the Care Quality Commission amends all appropriate core service frameworks to include risk controls identified in this report, to mitigate the risk of significant abnormal findings not being followed up.
Safety Recommendation
Management of acute onset testicular pain
It is recommended that the National Institute for Health and Care Excellence revises the content and accessibility of its Clinical Knowledge Summary on testicular torsion.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that NHS England/NHS Improvement evaluates current approaches to the clinical oversight of overdose calls within ambulance control rooms and leads on work to develop a national framework to describe the requirements for appropriate clinical oversight of overdose …
Safety Recommendation
The diagnosis of ectopic pregnancy
It is recommended that the Care Quality Commission Services Framework for Gynaecology and Termination Services includes an assessment of early pregnancy services, using as a reference the National Institute for Health and Care Excellence Guideline 126, Ectopic pregnancy and miscarriage: …
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
There are likely to be benefits for all organisations delivering anaesthesia to gain Anaesthesia Clinical Services Accreditation (ACSA) as this is likely to reduce unwarranted variation in practice.
Safety Observation
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It may be beneficial to evaluate the change in organisational risk tolerance to consider the potential future impact on NHS governance and regulation processes.
Safety Observation
Delays to intrapartum intervention once fetal compromise is suspected
It is recommended that the Care Quality Commission, in collaboration with relevant stakeholders, includes assessment of relational aspects such as multidisciplinary teamwork and psychological safety in its regulation of maternity units.
Safety Recommendation
Procurement, usability and adoption of ‘smart’ infusion pumps
NHS England and NHS Improvement.
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
Medicines and Healthcare products Regulatory Agency (MHRA)
Learning Prompt
Procurement, usability and adoption of ‘smart’ infusion pumps
Examples are needed of where safety cases have been used in the NHS to manage safety proactively, so that their value can be communicated and better understood. The NHS should always show evidence of rigorously considering safety in all procurement, …
Safety Observation
Placement of nasogastric tubes
The Trust where the reference event happened implemented and recorded training and competency assessments for all nursing staff prior to allowing them to insert and confirm placement of nasogastric tubes.
Safety Action
Placement of nasogastric tubes
The Trust where the reference event happened checked the hospital clinical areas to confirm there were no other areas holding non-CE marked pH testing strips for human gastric aspirate.
Safety Action
Placement of nasogastric tubes
The Trust where the reference event happened, amended the timing of its daily aspirate check from midnight to 10:00 hours.
Safety Action
Placement of nasogastric tubes
(previously shared in interim bulletin): It is important when transitioning between any types of bedside testing equipment (not just pH strips) the potential for confusion between old and new stock is considered, and the transition managed to reduce that risk …
Safety Observation
Placement of nasogastric tubes
(previously shared in interim bulletin): It is important that organisations are aware that there is not a standard scale/colour scheme across the different manufacturers of CE marked enteral testing strips and they vary in scale (pH of 1-12, 0-6, 2-9 …
Safety Observation
Placement of nasogastric tubes
It may be beneficial if accreditation for reviewing, recording and communication of the clinical evaluation of the X-ray findings, prior to initiation of feed, is limited to specific staff groups trained in confirming nasogastric tube placement, for example reporting radiographers …
Safety Observation
Placement of nasogastric tubes
It would be beneficial if the (recommended) national standardised competency-based training programme for nasogastric X-ray interpretation to confirm nasogastric tube placement will be made a contractual and/or regulatory requirement for all healthcare providers to implement and evidence ongoing compliance with.
Safety Observation
Placement of nasogastric tubes
It may be beneficial if national organisations including the Medicines and Healthcare products Regulatory Agency, NHS Supply Chain and NHS England and NHS Improvement review arrangements for ensuring all medical device related incidents, Yellow Card reports, or other device safety …
Safety Observation
Placement of nasogastric tubes
It would be beneficial if chest X-rays for acutely ill patients were reported by a radiologist, or a radiographer who has undertaken training, to enable them to report on examinations at an appropriate time. The report should include the position …
Safety Observation
Placement of nasogastric tubes
It is recommended that Health Education England coordinates the development and publication of a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing. The model may include simulation, observed practical assessment and ongoing competency assessment. …
Safety Recommendation
Placement of nasogastric tubes
It is recommended that the British Society of Gastrointestinal and Abdominal Radiologists, working with Health Education England and the Society and College of Radiographers, develops and publishes a national standardised competency-based training programme for X-ray interpretation to confirm NG tube …
Safety Recommendation
Placement of nasogastric tubes
It is recommended that NHS Supply Chain develops essential specifications to support the clinically-led procurement of devices to include devices to confirm NG tube placement, for example, pH testing strips. The essential specifications should set out a range of factors …
Safety Recommendation
Placement of nasogastric tubes
It is recommended that NHS Supply Chain and the British Standards Institution work together (engaging other system leaders as appropriate, such as the Medicines and Healthcare products Regulatory Agency and NHS England and NHS Improvement), to develop and publish an …
Safety Recommendation
Placement of nasogastric tubes
It is recommended that NHS England and NHS Improvement works with the Department of Health and Social Care and others, to identify the process by which the NHS can identify and commission necessary research to support improvements in patient safety. …
Safety Recommendation
Never events: analysis of HSIB's national investigations
Placement of nasogastric tubes (Healthcare Safety Investigation Branch, 2020c).
Learning Prompt
Never events: analysis of HSIB's national investigations
Wrong site surgery – wrong patient (Healthcare Safety Investigation Branch, 2020a).
Learning Prompt
Never events: analysis of HSIB's national investigations
Detection of retained vaginal swabs and tampons following childbirth (Healthcare Safety Investigation Branch, 2019b).
Learning Prompt
Never events: analysis of HSIB's national investigations
Piped supply of medical air and oxygen (Healthcare Safety Investigation Branch, 2019a).
Learning Prompt
NCEPOD recommendations(62)— showing 50 strongest matches
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Testicular Torsion
Wording not shown. See the report on NCEPOD's website.
Testicular Torsion
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
CQC inspection actions(2000)— showing 50 strongest matches
Wythenshawe Hospital
The service should continue to complete audits in line with the audit plan and keep the plan updated.
Should Do
Wythenshawe Hospital
The service should continue to address issues and concerns using quality improvement initiatives and ensure they can evidence the impact of improvements made.
Should Do
Wythenshawe Hospital
The service should ensure that incidents are appropriately graded to ensure they can assess, monitor and improve the quality of services to women and birthing people.
Should Do
Wythenshawe Hospital
The service must assess, monitor and improve the quality and safety of the services provided in a timely way. Regulation 17(2)(a)
Must Do
Worthing Hospital
The trust must ensure that workforce data for the trust can be separated to show individual site performance.
Must Do
Worthing Hospital
The trust must ensure action is taken to improve their compliance with national waiting list targets and that performance data for the trust can be separated to show site performance.
Must Do
Worthing Hospital
The trust must review its existing IPC audit monitoring systems to identify any shortfalls in infection prevention and control so action can be taken to make improvements when needed.
Must Do
Worthing Hospital
The trust must ensure that the systems used to monitor WHO checklist compliance, including brief and debrief, are effective in demonstrating compliance and able to show areas for improvement effectively in line with NPSA guidance.
Must Do
Worthing Hospital
The trust must ensure the monitoring of anaesthetic machine checks is recorded and aligns with best practice guidance.
Must Do
Worthing Hospital
The trust must review its audit monitoring systems to effectively improve the quality and safety of the services.
Must Do
Worcestershire Royal Hospital
The trust should consider how the service follows national guidelines, such as National Institute for Health and Care Excellence clinical guideline 83 (critical care rehabilitation).
Should Do
Worcestershire Royal Hospital
The trust should ensure timely and validated data is monitored to improve the quality and performance of the service, this may include submission to the Intensive Care National Audit and Research Centre.
Should Do
Worcestershire Royal Hospital
The trust should ensure a critical care outreach service is in line with national guidelines.
Should Do
Worcestershire Royal Hospital
The trust should have systems or processes to assess, monitor and identify improvements of the quality and safety of sepsis management.
Should Do
William Harvey Hospital
The trust should consider an audit process associated with why patients were transferred between CYP environments.
Should Do
William Harvey Hospital
The trust should consider systems and processes which support managers own oversight of training completion rates and renewal dates held centrally by the trust governance team.
Should Do
William Harvey Hospital
The trust should ensure they have systems and processes in place to ensure all incidents, regardless of whether they result in harm, are reported.
Should Do
William Harvey Hospital
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses. 17(2)(b): Good governance
Should Do
William Harvey Hospital
The trust should consider how Information is analysed and reviewed and its significance is understood. For example, how results should be escalated, and appropriate action taken. 17(2)(b): Good governance.
Should Do
William Harvey Hospital
The trust should ensure audits are accurate so they can be used to drive improvements in the service.
Should Do
William Harvey Hospital
The leadership team should consider how future leaders operationalise the vision and support continuation of work introduced by people in current interim roles.
Should Do
William Harvey 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
West Suffolk Hospital
The service must ensure governance arrangements establish timely compliance with national recommendations and ensure oversight of local audits.
Must Do
Westmorland General Hospital
The trust should ensure that wards are secured to maintain patient safety.
Should Do
Westmorland General Hospital
The trust should ensure senior leaders of the department have oversight of paediatric activity and performance in the ED.
Should Do
Westmorland General Hospital
The trust should consider giving emergency department managers access to view incidents that are graded no harm or low harm, in order that there is complete oversight of incidents in the department to ensure that they have been graded correctly …
Should Do
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Must Do
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Must Do
Westmorland General Hospital
The trust must implement an effective risk and governance system for the whole stroke pathway.
Must Do
Westmorland General Hospital
The service must ensure they participate in clinical audit to demonstrate the effectiveness of care and treatment.
Must Do
Westmorland General Hospital
The trust must ensure they establish and operate effective governance processes and systems, with robust action plans to monitor and improve the safety and quality of services and mitigate risks to women and families using the service.
Must Do
Westmorland General Hospital
The trust must implement an effective risk and governance system for the whole stroke pathway.
Must Do
Westmorland General Hospital
The department must ensure that all known risks are singularly identified on the risk register and that risks are supported by robust action plans that can reduce or mitigate the risks. They must also ensure that these action plans are …
Must Do
Westmorland General Hospital
The service must ensure that audit information (including national audits) is submitted, up to date, accurate and properly analysed and reviewed by people with the appropriate skills and competence to understand its significance. When required, results should be escalated, and …
Must Do
Westmorland General Hospital
The trust must ensure that incidents are identified, graded appropriately to reflect the level of harm and that they are acted upon and investigated in a timely way.
Must Do
Westmorland General Hospital
The trust must ensure that risks in the organisation are correctly identified and appropriate mitigations put in place in a timely way
Must Do
Westmorland General Hospital
The trust must ensure that governance processes are robust and effective
Must Do
Wavertree Bungalow
The provider and registered manager must effectively monitor all key aspects of the safety and quality of the service being provided.
Must Do
Wavertree Bungalow
The provider must ensure that monitoring of the safety of the service takes place and is effective.
Must Do
Watford General Hospital
The trust should consider manager oversight where ward managers are absent, to monitor equipment checking and staff well being.
Should Do
University Hospital of Hartlepool
The service should ensure that they clearly document mitigating actions taken for each risk on the risk register and evidence they monitor and manage risks appropriately.
Should Do
University Hospital of Hartlepool
The service should create and monitor action plans with clear actions, timescales and action owners.
Should Do
University Hospital of Hartlepool
The service should ensure that incidents are reviewed and thoroughly investigated by competent staff, and monitored to make sure that action is taken to remedy the situation, prevent further occurrences and make sure that improvements are made as a result.
Should Do
University Hospital of Hartlepool
The service must ensure there are systems and processes in place to assess, monitor and improve the quality and safety of the services in respect of restrictive practices.
Must Do
University Hospital of Hartlepool
The service must ensure appropriate midwifery leadership is in place.
Must Do
University Hospital of Hartlepool
The service must ensure effective governance structures are in place to continually improve the quality and standards of care
Must Do
University Hospital of Hartlepool
The service must ensure that all care of women and their babies is undertaken in line with national guidance and best practice.
Must Do
University Hospital of Hartlepool
The trust must strengthen the oversight of divisional and ‘ward to board’ governance.
Must Do
University Hospital of Hartlepool
The trust must ensure effective operational oversight of risk, issues and performance.
Must Do
Tudor Lodge
Safe care and treatment
Must Do
ICIBI immigration recommendations(8)
An inspection of illegal working enforcement (August – October 2023)
In relation to assurance: (a) as a matter of priority, re-introduce a formal first-line assurance process. (b) ensure that second-line assurance covers all operational areas, including planning activity. (c) review …
An inspection of asylum casework (August 2020 – May 2021)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (June – October 2023)
Ensure all first line quality assurance takes place before asylum decisions are served. Ensure that trends in Second Pair of Eyes (SPoE) feedback are identified and analysed, and that the …
An inspection of asylum casework (August 2020 – May 2021)
Introduce Calibre assurance assessments for screening interviews
A further inspection of the EU Settlement Scheme (July 2020 – March …
Recommendation 5 Review the robustness of the quality assurance regimes in place for EU Settlement Scheme (EUSS) caseworkers and Settlement Resolution Centre (SRC) staff, in the process explaining to staff …
An inspection of visit visa operations December 2022 to January 2023
Improve the existing first-line assurance regime to cover all operational grades and processes, with a focus on routing and decision quality
An inspection of asylum casework (June – October 2023)
Introduce Calibre assurance assessments for screening interviews
An inspection of Border Force practice and procedures in relation to firearms …
Review the current Border Force Assurance Expectations, to ensure that all risks in relation to firearms identification, handling, storage, and transport are subject to adequate first and second-line assurance.
PPO death in custody recommendations(6)
Manx Care
Manx Care should have a dedicated clinical governance lead responsible for prison healthcare at Isle of Man Prison to ensure practice is compliant and underpinned by national guidance, legislation and evidence-based practice.
The Chief Executive of NHS Wales
The Chief Executive of NHS Wales should ensure that prison dental surgeries in Wales are subjected to the same level of scrutiny and inspection as community dental surgeries.
The Governor
The Governor should review whether the quality assurance process for escort risk assessments is sufficiently robust and consider introducing SLT review of a random sample to identify any ongoing issues.
The HMPPS Executive Director for Custodial Contracts
The HMPPS Executive Director for Custodial Contracts should write to the Ombudsman setting out what he has done to satisfy himself that healthcare services at Rye Hill, including the contract for GP services, meet the needs of the prison’s population.
The Director
a robust quality assurance process is implemented to check that these measures are in place and effective.
The Governor
The Governor should review the quality and compliance with policy of ACCT management in the previous 12 months, identify any improvements required, and devise a plan to deliver those improvements.
IOPC learning recommendations(16)
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take steps to ensure there is effective supervision and quality assurance in place for officers where there is little measurable work output to review, to ensure the maintenance of policing standards and officers’ …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should assure itself that sufficient steps have been taken to ensure appropriate supervision and welfare is in place to prevent officers becoming isolated through their duties. This follows an investigation into allegations of misconduct …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should continue to adhere to their dip sampling policy of domestic violence cases in order to identify any improvement opportunities and put in place a clear and robust and documented plan for remedial action …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police ensures that the quality of the cell checks conducted by detention officers are regularly monitored by their supervisors, and any concerns are recorded and fed back to them. This follows an investigation into …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should review the processes through which the Flexible Lift and Carry System (FLACS) and other operational equipment are introduced and reviewed and ensure these are aligned with the most recent …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should take appropriate steps to assure itself that the bullying and harassment identified through Operation Hotton is not more widely prevalent across the MPS. This follows an investigation into allegations of bullying and harassment …
Police investigation into how a child sustained injuries – Cleveland Police, February …
The IOPC recommends that Cleveland Police should review the systems in place for supervisory entries onto Occurrence Enquiry Logs (OEL’s) to ensure that in future criminal investigation cases it is not possible for one person to be both the Officer …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that that when closing domestic violence cases Northumbria Police should put in place a system of supervisory oversight in line with the HMICFRS VAWG Report Recommendation update dated 13 June 2023. This will allow supervisory oversight and …
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) considers the development of a system which automatically notifies the Directorate of Professional Standards (DPS) of when a serving police officer is linked to an ongoing police investigation. This follows an …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) requires all forces to ensure they have mechanisms for recording the use of Flexible Lift and Carry Systems (FLACS), and similar manual handling devices, thereby providing a clear auditable process …
Recommendations - National Police Chiefs' Council, December 2024
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should undertake medical testing of the Flexible Lift and Carry System (FLACS) independent of the manufacturer. This should include testing of whether the FLACS can be safely used after a …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should remind staff of their responsibility to identify and respond appropriately to vulnerable victims and that supervision of incidents concerning vulnerable victims is robust and effective and that all available evidence/intelligence is imputed onto …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police review training for Call Centre staff with regard to risk grading and that domestic violence incidents graded 1 or 2 receive a prompt response. This should be done by continuous dip sampling to check …
Investigation into police pursuit and subsequent road traffic incident - Metropolitan Police …
The IOPC recommends the Metropolitan Police Service establish if car radios fitted in police response vehicle are fit for purpose, are in full working order and the audio function works appropriately. They should also reinforce to officers the necessity to …
Investigation into recruitment irregularities and the actions of a civilian staff member …
The IOPC recommends that British Transport Police reviews the current practice of passing investigations between different teams within the Professional Standards Department and different appropriate authority delegates and sets out clear roles and responsibilities for all those involved in carrying …
Investigation into recruitment irregularities and the actions of a civilian staff member …
The IOPC recommends that British Transport Police considers working practices in the Professional Standards Department to consider and take action to address any issues with: - how evidence relied on to form views and conclusion is detailed in investigation reports …
NAO audit recommendations(16)
NHSE's management of elective care transformation programmes
NHSE plans to reset its central oversight arrangements for elective recovery. As it establishes its new national level oversight board for the transformation programmes it should: ? ensure that performance information reported to the board is prioritised, clear and consistent …
Accepted
Financial sustainability of colleges in England
d) Evaluate, and take action to improve, the effectiveness of the early and formal intervention regimes in improving colleges’ financial sustainability. At a time of significant funding and cost pressures, intervening successfully is particularly challenging. However, it is important for …
Accepted
Resilience to animal disease
b support APHA to improve its systems and processes in ways that will ensure more efficient and effective responses to outbreaks; this could include providing ongoing support for APHA?s Delivering Sustainable Future programme;
Accepted
NHSE's management of elective care transformation programmes
NHSE should do more to secure buy-in from clinicians across its programmes. It should achieve this by: ? continuing to build support and endorsement nationally by strengthening its work with Royal Colleges and through national clinical directors embedded in the …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 5: NHSE should revisit internal quality assurance arrangements for existing models when they are used for a new purpose, such as the models used to provide input data for the workforce modelling, and ensure independent scrutiny is evidenced accordingly.
Accepted
Progress in improving mental health services in England
e) As mental health services will need to remain the focus of sustained improvement and in the light of national and local reorganisation of health bodies, DHSC and NHSE should set out the future approach to leading, monitoring and assuring …
Accepted
Progress in improving mental health services in England
c) NHSE, working with local ICBs and providers, should improve its data and analysis to better understand the relative cost and cost-effectiveness of different services, and provide a more robust basis to decide future priorities.
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
d) by April 2023, NHSE should fully align its oversight of ICBs with the strategic objectives for ICSs. Specifically, it should: ? agree with ICBs what they can realistically deliver against each of the four purposes, taking account of individual …
Accepted
NHS financial management and sustainability
NHSE&I should put in place a regulatory and oversight system that aligns with the responsibilities placed upon individual NHS bodies and their role within non-statutory sustainability and transformation partnerships and integrated care systems. This should clearly set out how roles …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 7: Modelling of this kind requires gathering assumptions about the future of the NHS in one place. This presents an opportunity to expose those assumptions widely to scrutiny and challenge, both internally and externally. Assumptions should be generated in …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 4: NHSE should ensure quality assurance practices take place in a timely manner, so analysts have sufficient time to respond accordingly.
Accepted
Progress in improving mental health services in England
d) NHSE, working with ICBs, should develop and issue guidance in 2023 on how the system will gain more transparency over capacity, activity, performance and outcomes in community mental health services, including improvements required to implement the proposed new clinical …
Partially accepted
Government Shared Services
f) Departments working together as clusters should complete individual ?declarations? that set out agreed ways of working and reaffirm their commitment to the Shared Services Strategy. This should be signed by each departmental accounting officer.
Accepted
Government Shared Services
c) The Cabinet Office should streamline its central governance arrangements so that they avoid duplication and unnecessary work for departments.
Accepted
Government Shared Services
e) Departments should establish cluster-level governance arrangements to avoid duplication in decision-making and to embed the cluster model. It should no longer use existing departmental governance routes to approve high-level strategy decisions.
Accepted
Introducing Integrated Care Systems: joining up local services to improve health outcomes
e) NHSE should evaluate whether it can draw lessons from the simplified system of commissioning and contracting arrangements put in place for the NHS during 2020-21 and 2021-22, and streamline the requests made to front-line providers while retaining the information …
Accepted
PHSO ombudsman recommendations(5)
Ignoring the alarms: How NHS eating disorder services are failing patients
Both NHS Improvement and NHS England have a leadership role to play in supporting local NHS providers and CCGs to conduct and learn from serious incident investigations, including those that are complex and cross organisational boundaries.
Ignoring the alarms: How NHS eating disorder services are failing patients
NICE should consider including coordination as an element of their new Quality Standard for Eating Disorders.
Broken trust: making patient safety more than just a promise
The Department of Health and Social Care should commission an independent review of what an effective set of patient safety oversight bodies would look like. The review must include meaningful engagement with NHS leaders, staff, patients and families.
Broken trust: making patient safety more than just a promise
As part of their quality monitoring role, the PSIRF executive lead on each Board should look at any discrepancies between local and PHSO investigations, or other independent investigations, and make sure the Board discusses them. This should include where local …
Broken trust: making patient safety more than just a promise
Integrated care boards, with oversight from NHS England, should closely monitor the impact of the PSIRF to identify any negative consequences of the new flexibility it offers, which gives Trusts more autonomy to decide when a patient safety investigation is …
IMB annual reports(2)
Hull (2021)
During the reporting year dominated by COVID-19, HMP Hull remained a safe prison with reduced violence and aggression, despite two self-inflicted deaths. Staff and prisoners collaborated well, and new communication and education methods supported coping. However, pandemic restrictions severely limited prisoners' time out of cells to approximately one hour daily, highlighting issues with shared Victorian cells. While healthcare provision was maintained under pressure, the Board raised concerns about the management oversight of the external provider (CHCP) and the complexity of the complaints system.
PRISON
Key concerns
Exeter (2022)
HMP Exeter, a Category B local and resettlement prison, experienced persistent high levels of violence and self-harm, alongside challenges with staffing instability and extensive refurbishment work in 2022. While healthcare provision was generally satisfactory, access to psychological therapies remained limited, and living conditions were often impacted by overcrowding and restricted regimes. Progress towards successful resettlement was hindered by short sentences, lack of work opportunities, and staff shortages.
PRISON
Key concerns
IMB individual recommendations(8)
Winchester (2024)
What can be done to further hold to account Practice Plus Group's activities for the purposes of monitoring delivery of healthcare services under terms of contract and PSO1700?
HMPPS
In Progress
Elmley (2024)
Address the inconsistency in the quality of ACCT documents through effective quality assurance.
Governor / Director
Humber (2023)
The Board acknowledges the 12 key concerns identified by HMIP in its recent report and agrees they should be progressed during the coming reporting year, subject to the necessary resources being available. The Board will endeavour to structure its monitoring to reflect these concerns and the progress made in addressing them.
Governor / Director
Thorn Cross (2024)
To provide the Board with regular and timely evaluation of all aspects of the prison’s performance.
Governor / Director
Leicester (2022)
The Board would like to draw the minister’s attention to its continued concerns about the service provided (5.1.2).
Ministry of Justice
Gartree (2022)
Therefore, can the Minister confirm to the Board that all services being provided to Gartree by outside organisations (e.g. healthcare, maintenance and education) are achieving all quality and performance targets for the services they have been commissioned to provide?
Ministry of Justice
Hollesley Bay (2024)
The Board is pleased to acknowledge the very positive result of the unannounced HMIP inspection in April. It also notes the positive comments by the Chief Inspector.
Governor / Director
Noted
Wakefield (2022)
We ask the minister and his/her officials to explain how the ministry perceives the performance of prisoner healthcare at HMP Wakefield when compared against the performance specification in the contract.
Ministry of Justice
Noted
Health investigations(2174)
Independent investigation: Alan Riddock, Bristol (2008) — Rec 10
Bristol PCT should ensure that it has in place policies and procedures which ensure that: • it is informed of any serious adverse incident in a timely manner; • standards for the quality and time scale of investigations are in place; • the role of Bristol PCT in assuring that …
south_west
Independent investigation: Alan Geddes, Aberdeen (2019) — Rec 6
HSCP A should carry out regular audit of the quality of social circumstances reports as required by standard 7 of the National Standards for Mental Health Officer Services.
scotland
Independent investigation: Alan Creasey, Lancing (2017) — Rec 6
An annual audit programme is required which tests the effectiveness of the Trust’s investigation processes against best practice and national guidance. This should include a review of the application of RCA methodology, the panel review process, and the quality assurance of the final report.
south_east
Independent investigation: Alan Creasey, Lancing (2017) — Rec 5
The CCG must ensure that incidents are only closed once full assurance has been gained that an appropriate investigation has been undertaken.
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xxi)
The Trust should conduct investigations into serious incidents according to the current guidelines and frame terms of reference so that they extend to examination of material policies and procedures.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xx)
The Trust and Council should audit the outcomes of the CPA procedures at intervals of not less than two years and should revise them as necessary.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xiii)
The Trust should carry out a review of the arrangements for monitoring in the depot clinics.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xii)
The Trust and Council should ensure that arrangements are effectively in place for regular monitoring by professionals of the mental state of every service user who is considered to be at risk of relapse.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (x)
The Trust and Council should undertake an audit of the process of care co ordination with a view to establishing that suitable professionals are being assigned to service users on Enhanced CPA and that co-ordination is being effectively carried out in accordance with the current Practice Guidelines.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (v)
The Trust and Council should ensure that every service user is accurately categorised as a Standard or Enhanced CPA case.
london
Independent investigation: Sidney Waller, Manchester (2008) — Rec 9
The PCT in collaboration with the Mental Health Trust should review the commissioning and provision of specialist services for people with Personality Disorder. This review should: consider the effectiveness of current Personality Disorder services against NICE and DH guidelines; consider the accessibility of current Personality Disorder services against NICE and …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 8
The PCT will monitor the ongoing progress and implementation of all requirements and recommendations in relation to Assertive Outreach Services in their monthly monitoring meeting and report any issues to the Joint Commissioning Executive and the PCT Board where appropriate.
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 7
In conjunction with the Mental Health Trust the PCT will consider the Assertive Outreach service delivery model and reassess this in relation to its compliance for policy implementation guidance and will consider this in relation to any transformation change programmes to ensure that the service adheres to national and local …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 4
The PCT must receive assurances in relation to the clinical and managerial supervision of all staff and this must be tied in with a robust audit process and an assurance process to demonstrate that the evidence is in place and meets all the requirements of supervision.
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 3
Clear performance targets and measurable outcomes need to be included in the monitoring and management of the Assertive Outreach Service. The PCT needs to address these within the routine monthly contract monitoring meetings and be provided with assurances that all performance targets are being met.
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 1
Quality indicators must be monitored closely and it must be ensured that they are delivered in relation to CPA, governance, supervision and the model of care. It is recommended that a tailor-made audit be completed with the Assertive Outreach Service to assess the service and the delivery of the outlined …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 8
The Trust has made significant alterations to its professional management and leadership structures. These arrangements should be reviewed in order to understand their effectiveness with particular regard to: clinical supervision practice, effectiveness and professional regulation; the implementation and development of professional leadership strategies; the integration of designated professional leaders within …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 6
There should be a review of the model of care provided by the Assertive Outreach Team which should include a range of monitoring tools. This review should also examine the stated philosophy of care ensuring that clinical best practice issues are held in balance with those of the service user’s …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 5
The revised management arrangements for the Assertive Outreach Team should be reviewed to ensure they are working in line with the recommendations made by the Trust internal review. In order to ensure the success of the previous recommendation an audit should be conducted to evaluate progress made against: clinical record …
north_west
Independent investigation: Sidney Waller, Manchester (2008) — Rec 3
The Trust should ensure that there is an appropriate level of adherence to policy and procedure through systematic audit processes. Where adherence is not happening, remedial action should be taken. The Trust will conduct clinical audits for CPA and risk assessment on the completion of the publication of this report …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 16
The Trust should ensure that all Trust employees are aware of the requirement to take part in clinical supervision. This requirement should be made explicit and compliance should also be audited on a regular basis.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 14
The Trust should audit the effectiveness of the new electronic record system on a random sampling basis at six monthly intervals for the first year of running and on an annual basis thereafter.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 9
The Trust should implement the recommendations and action plan of the CPA steering group and re audit compliance 12 months following its implementation/ or the publication of this report, whichever comes first. This review should: ensure that service users who are previously unknown to the service and make their first …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 7
The Trust review should examine the effectiveness of the MDT process six months post implementation/following the publication of this report, whichever occurs first.
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 17
All agencies should review their current policies and procedures in the light of this report, and in accordance with clinical governance and performance policies.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 10
Trusts and social services should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 9
Trusts and social services should establish a system of random audit to ensure that Home Office Guidelines are followed.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 15
All agencies should review their current policies and procedures in the light of this report, and in accordance with clinical governance and performance management policies.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 5
Social services and trusts should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
Social services and trusts should establish a system of random audit to ensure that Home Office Guidelines are followed.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 14
All agencies should review their current policies and procedures in the light of this report.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 11
The Home Office should establish a system of notifying the appropriate director of either clinical services or social services where reports are late.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 10
The Home Office should require supervisors to undertake an annual case review, with a particular emphasis on long-term goals. Reports of these meetings should be considered by the Home Office at its annual review, together with that year’s CPA and case-conference records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
Restricted patients should be seen by a consultant psychiatrist acting as psychiatric supervisor. If seen by a specialist registrar there should be regular, recorded consultant supervision.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 5
The Health Authorities or their successors should indicate to the relevant bodies their intention to review the progress of this report’s recommendations, initially at 6-months. The inquiry panel members should be included in this review.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
All agencies should review their current policies and procedures in the light of this report and in accordance with clinical governance policies.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
Trusts and social services should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 3
All agencies should review their current policies and procedures in the light of this report.
south_east
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 14
The Trust has accomplished a significant amount of work in relation to clinical governance processes. The Trust should audit progress against the new systems within six months of the publication of this report. This audit should be framed in conjunction with commissioners and should provide assurance in the public interest …
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 13
The Trust and Local Authority should develop a cycle of audit that tests policy to practice for all policies and procedures linked to the delivery of care planning and treatment. These audits must: be developed in conjunction with commissioners; include NICE treatment guidelines; form links with case, clinical and managerial …
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 8
The Trust and Local Authority should develop a framework of assurance that will measure policy to practice. This framework must: be developed with local commissioners; be based upon national best practice guidance.
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 7
The Trust and Local Authority should develop in conjunction with its commissioners a robust performance management tool to ensure that the new care pathways are effective and are implemented as currently planned. (Please see Recommendation 1).
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 2
All patients must receive a diagnosis and diagnostic formulation following assessment. This activity will be monitored through: clinical audit processes; medical appraisal.
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 1
It is recommended that the Trust and Local Authority develop a range of key performance indicators to monitor access to care and treatment within the new models of care. These key performance indicators are to be developed: in conjunction with the commissioners of mental health services; in accordance with national …
north_west
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xviii)
The Health Authority should monitor the performance by the Trust of its obligations under the CPA.
london
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (vii)
The Trust should devise and implement a procedure whereby a patient who has attended at the Out-patient Clinic for a period in excess of one year is thereafter invariably seen by a Consultant.
london
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 9
Access to appropriate family interventions should be available to services users under the care of the CMHT. CMHT staff should receive training and supervision in appropriate family work and interventions. The Trust should monitor the provision of this service, including using regular audits, to ensure that those individuals who might …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 8
The Trust should assure itself and its Local Authority partners that the Safeguarding policies and procedures which it has put in place and supported with training are being implemented. It should include audits of compliance with its Safeguarding policies in its regular audit cycle.
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 5
The Trust has identified that progress has been made in the delivery of substance misuse services. It should now put in place a system, including an audit cycle, to assure itself and its commissioners that these developments are realising the intended and identified outcomes. The Trust has identified a number …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 2
Having revised its risk assessment, mangement and training policy the Trust should institute a regular quality audit to ensure: that the formulation of the individual’s problems and needs informs the understanding of his/her risk; that robust and meaningful care plans are put in place; that the service user and other …
north_east_yorkshire
Scottish Fatal Accident Inquiries(106)
Gordon Scott Niven
I accordingly recommend that the issue should be addressed as a matter of priority by those bodies having professional interest, in particular The Faculty of Accident and Emergency Medicine and the Society of British Neurological Surgeons.
Mar 1999
Darren Denholm
I recommend that consideration is now given, by the Executive or Parliament if that is required, to the discontinuation of administering general anaesthesia for dental treatment in dental surgeries.
Feb 2000
Hamish Adamson
The management of the Trust and the senior medical and midwifery management at Cresswell should carry out an urgent and thorough review of the practices and procedures at Cresswell in relation to a trial of labour by induction by prostaglandin gel by a woman who has previously undergone a caesarean section operation with particular reference to • The time of …
Dec 2000
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
William George Henderson and others (Airtours)
It is recommended in addition that the CAA should consider requiring that for a suitable period of time (whose duration they should determine) the result of each 200-hour inspection of the starter adapter and crankshaft gears in GTSIO-520 series engines (carried out under Critical Service Bulletin CSB94-4D or any subsequent edition thereof) should be reported to them, whether or not …
Sep 2002
Sharman Weir
I recommend: (a)That the Queen Mother's Hospital should identify a lead obstetric consultant to develop a system for the management of patients with pre-eclampsia and eclampsia. This should include protocol development and updating, and appropriate staff training. (b)That the training of all junior medical staff at the Queen Mother's Hospital should include their being taught (1) about the potential seriousness …
Jan 2003
Stephen Park
This is plainly unsatisfactory and I recommend that the police carry out an audit of their training schedules to ensure that every member of staff who serves in or may be called to serve in the custody suite has received the appropriate and up to date training.
Jul 2003
William Sneddon, Lemond Milroy, David Brodie McFarlane and Agnes McCoull
When corresponding with patients or their relatives in relation to concerns expressed about their care in hospital the Trust should be careful to distinguish between medical treatment, nursing care and other concerns. The management of the Trust and the senior medical management at Dumfries and Galloway Royal Infirmary should carry out an urgent and thorough review of the practices and …
Jan 2004
Emma Agnes Frame
Accordingly I would recommend that there be a review of the practice in Yorkhill relating to first referrals of a child in order to establish whether a staightforward system to achieve this might be put in place.
May 2005
Margaret Graham
I would merely express the hope that, if there is not already in place an effective procedure for the regular and comprehensive review of the hospital's systems to ensure that it continues to serve the fundamental purposes for which it exists, then such a procedure should be introduced now.
Apr 2006
Timothy Andrew Peter Cook
5. That consideration should be given to fitting airborne flight data and cockpit voice recording equipment on all commercial air transport. 6. That recordings be made of all military radar returns for analysis by the Department for Transport Air Accidents Investigation Branch.
Mar 2007
Thomas Bolesworth
Accordingly, I take this opportunity to emphasise to all small businesses that it is the duty of every employer to ensure, so far as is reasonably practicable, the health and safety and welfare at work of all his employees. It is not sufficient only to rely upon advice and guidance given to by Environmental Health Officers or other inspectors charged …
Jan 2008
Guy Henderson and John McCreanor
Safety Recommendation 2006-101: The European Aviation Safety Agency and Joint Aviation Authorities should review the UK Civil Aviation Authority’s proposal to mandate the fitment of upper torso restraints on all seats of existing Transport Category (Passenger) aeroplanes below 5700kg being operated for public transport and consider creating regulation to implement the intent of the proposal. Safety Recommendation 2006-102: Considering the …
Aug 2008
Kevin West
The lack of an effective system of supervision, resulting in his being able to operate in this way, was clearly a defect in the system of working which contributed to the accident. It was also a significant defect in that in construction work it may frequently be tempting to make the job easier by cutting corners and taking risks and …
Mar 2009
Kaylee Susan McIntosh
That was a defect in a system of working and requires urgent attention. In my view, some form of cross-checking in respect of the issue of lifesaving equipment would be appropriate to prevent the recurrence of the issue of the wrong equipment.
May 2009
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
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
Andrew Andrews
I am not in a position to make any specific recommendations in this regard, but would expect and recommend that further consideration be given to the issues raised by the Health and Safety Executive.
Apr 2010
Laura McDairmant
Recommendation 1. (9) I heard evidence from Gavin Howat, Inspector of Health and Safety, who is employed by the Health and Safety Executive. He has specialised in the regulation of adventure activities within the Health and Safety Executive and has a wealth of experience in the sector. (10) Mr Howat advised the Inquiry that H.S.E. now has the responsibility for …
Jun 2010
Kristoffer Batt
In my view, the light and buzzer system should be extended to these areas, and I so recommend. [305] Perhaps more importantly, however, I recommend that there be installed an extension of the assistance light system to the charge bar, in order that the Custody Sergeant on duty can readily see whether Custody Care Assistants are responding promptly to requests …
Jul 2010
William Casuga Antonio
Owners should make them available and require their use unless, on a balanced assessment, the hazards of wearing them can reasonably be said to outweigh the benefits of wearing them. I have made a determination to this effect under Section 6(1)(e).
Oct 2010
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
Norma Haq
(4) In terms of Section 6(1)(e) of the said Act the death ought to have been reported to the procurator fiscal in terms of the literature "Death and the Procurator Fiscal"; said literature ought to be sent by the Scottish Executive to managers of private hospitals in addition to NHS hospitals; management in NHS and private hospitals should ensure that …
Apr 1998
Jamesina MacKenzie
It is management’s responsibility to remind staff of their primary duty to the residents and to monitor staff’s fulfilment of that duty. What can be said however, and on this I do agree with the Procurator Fiscal, is that there is a role in the Care Inspectorate in considering the level of medical and nursing expertise available to the care …
Jul 2012
Ronald William McAllister
That a comprehensive review be undertaken by greater Glasgow Health Board as soon as reasonably practicable of the following; (i) the training of staff involved in the delivery of haemodialysis to patients; (ii) the procedures for documenting and recording the checks conducted on patients during sessions of haemodialysis; and (iii) the auditing of the practice and procedures in place for …
Mar 2013
Alan David Bussell
I would suggest that any safe system of work is assisted, and encouraged, by the use of visual reminders. It may be of assistance if written warning labels were affixed to the RC console and to the crane boom, to reinforce the practice of isolating the RC console every time the operator approaches the crane.
Feb 2015
James Lochrie
Therefore, in view of findings 3 to 7 (inclusive) the Sheriff respectfully recommends that consideration be given by The Secretary of State for Transport as to whether appropriate legislation is required to:- (1) provide that a condition of holding or continuing to hold a licence to drive any class of vehicle is that the licence holder is deemed to consent …
Patricia Janette Wishart
All that we can hope for is that any publicity given to this case will encourage farmers and crofters to pay attention to the published advice of the Health and Safety Executive and the National Farmers Union who, I am told, in the week when this inquiry took place launched a campaign to raise awareness of the dangers which exist …
Jul 2016
Gary Daniel Forbes
(i) That the Maritime and Coastguard Agency give consideration to amending The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997 so that they apply to share fishermen, thereby requiring all persons on board fishing vessels to wear personal flotation devices or lifejackets when working on deck. (ii) That the Maritime and Coastguard Agency give consideration to …
Aug 2016
Stuart John Whitehead
I can identify that tying or footing the ladder would have prevented the accident. I would accordingly recommend these work practices.
Aug 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
William Black
In all the circumstances of the case there are no formal recommendations to make given the changes that have already been made to the system of working by the council, other than to recommend that all external workers are supplied with the council’s Health & Safety Handbook (the Blue Book).
Aug 2021
Przemyslaw Krawczyk - Duncan MacDougall
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 stability awareness training be made mandatory for masters of fishing vessels of between 7 and 16 metres in length.
Dec 2021
Richard Angus Scott Farquhar
The sheriff, in terms of section 26(1)(b) of the 2016 Act, and having regard to the matters mentioned in section 26(4) of that Act, Recommends that the Scottish Prison Service: (1) Require Risk Management Teams to agree, and keep under review, timescales for the completion of actions which form part a prisoner’s progression plan, including those actions which are agreed …
Jun 2022
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
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
Thomas Oliver Hill
The Sheriff, in terms of section 26(1)(b) of the Act, and having regard to the matters mentioned in section 26(4) of the Act, Recommends that: [1] Local authorities in Scotland should consider making it a condition of any licence issued in terms of The Civic Government (Scotland) Act 1982 (Licensing of Short-term Lets) Order 2022 that licence holders provide specific …
Sep 2023
Eric McLeod
a) The Company should ensure that it maintains an adequate, risk assessed and documented system to monitor and supervise all of its employees who engage in lone working. b) The Company should ensure that all of its employees who engage in trade and maintenance work receive work at height training.
May 2024
Chloe Morrison
1. That the operators of any LGV, or heavy goods vehicle (“HGV”), which is fitted with outriggers should take steps to ensure that any driver operating such a vehicle be trained to ensure that outriggers are safely stowed prior to the commencement of any journey. 2. That the operators of any LGV or HGV fitted with outriggers ensure that drivers …
Jan 2025
James Osbourne Murray
[141] There are two recommendations which I wish to make. [142] Firstly, I have seen nothing to suggest that Interflex have reviewed their health and safety procedures in the same way that Drummond Distribution have. If that has not been carried out by Interflex, I recommend they do so immediately. They should review existing (or prepare new) risk assessments, identify …
Feb 2026
Norman Mackenzie
Jun 2026
Norman Mackenzie
Jun 2026
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
George Donald McLellan
It could, and probably should, be the vehicle for a root and branch re-examination of the current practices and planned changes within the eight police forces, with a view to creating a system that meets the needs of a changing prisoner population. They are as follows: (a) A procedure for confirming and countersigning the vulnerability assessment of a prisoner at …
Jul 2007
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
Police Constable Kevin Lowe
This dilemma has been addressed by Lothian and Borders Police and Strathclyde Police may wish to consider how it is dealt with in that Force. The guidance therefore would not seem to be clear as I read it to be, because I have two interpretations of it from senior police officers and if it is ambiguous as Superintendent Docherty himself …
Nov 2007
Douglas John Armstrong
On the matter of a check-in or buddy system for a lone worker, whilst it was suggested that such a system was not popular and could result in unnecessary searches where a lone worker omitted, as requested, to check in, I accepted the evidence of Mr Murray that such a system should be in place.
Aug 2008
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
Detention investigations(12)
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 41
In general, I believe that Boards in IRCs (as in prisons) need to develop a range of techniques for taking the temperature of an institution in addition to formal applications and walking the site. I think the idea of regular 'surgeries' could also be added to the list above, and …
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 42
The Home Offce should strengthen its own assurance processes to examine adherence to professional standards and staff culture in IRCs on a regular basis.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 46
I recommend that IND gives urgent consideration to contract monitoring in relation to all holding rooms.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 43
The computerised monitoring schedule needs to be redesigned to make it more flexible and adaptable in monitoring and recording non-commercial aspects of the contract; A training analysis should be conducted across monitoring teams to ascertain the levels of understanding surrounding issues of passive discrimination. The above recommendations should be applied …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 42
I recommend that IND and the National Council of IMBs take steps to provide IMB scrutiny of all areas (that is, vans and holding areas) where detainees are held.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 40
I recommend that the IMB carry out more frequent, unannounced visits between 9:00pm and 9:00am in order to assess the centre during all its hours of operation.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 50
I also recommend that the performance of the RFU – in terms both of facilitating removals and forestalling problems between the contractor and the detainee – is monitored with a view to introducing a RFU at other ports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 47
I recommend that IND considers the advantages and practicality of contract monitors carrying out investigations into allegations against staff in other centres.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R10
The SMT should undertake unannounced observation of training sessions as part of the evaluation and quality assurance of training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R9
The SMT and G4S managers should undertake regular and systematic evaluation and quality assurance of the training provided at Gatwick IRCs to ensure that staff receive training of a consistently high standard; that it meets the operational needs of the IRCs, trains and develops staff appropriately and promotes appropriate values. …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 47
IND reviews and clarifies its role in overseeing the operation of removal centres, notwithstanding principles pertaining to transfer of risk.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 39
I recommend that Oakington’s IMB members be offered refresher training in relation to their powers and how to ensure maximum effectiveness.
Immigration Detention
Independent reviews(50)
Dearing 16-19 Review — Rec 12
The joint committee of the NCVQ and SCAA should, in consultation with centres, awarding bodies and representatives of higher education and employment, oversee the development of a common framework for the quality assurance of all national qualifications. (Section 3.43.)
Education
Youth Justice Board Review — Rec 16
The YJB should develop internal KPIs that focus on: • the quality of youth justice services, as graded by HMIP • outcome measures – a reduction in children and young people in custody, reoffending and first-time entrants • equality measures – including, but not only, racial disproportionality and in particular …
Justice & Legal
Youth Justice Board Review — Rec 15
The YJB to review the structure of its regional oversight team so that it has the right level of expertise, can assess performance, intervene where required, prioritise sharing best practice and drive continuous improvement.
Justice & Legal
Youth Justice Board Review — Rec 14
The YJB to fully implement the recommendations made in the GIAA report on the Performance Oversight Framework.
Justice & Legal
Youth Justice Board Review — Rec 13
Twelve months after the first publication of the new KPIs, the YJB and MOJ’s YJPU should work together to review and assess how useful the KPIs have been in: (1) facilitating better partnership working and service improvements, (2) sharing best practice, and (3) identifying where to target support.
Justice & Legal
Youth Justice Board Review — Rec 12
The YJB to publish data around the new KPIs as soon as possible and share the data regularly with youth justice services, MOJ’s YJPU and other government departments to inform decision making. The YJB to undertake greater engagement with the sector around how these KPIs fit with its performance oversight …
Justice & Legal
Youth Justice Board Review — Rec 11
The YJB should seek to analyse and publish AssetPlus data. This information should then be used by MOJ’s YJPU to inform policy decisions, and by youth justice services to develop greater insight into their services and improve decision making on the needs of children and young people.
Justice & Legal
Youth Justice Board Review — Rec 1
MOJ’s Youth Justice Policy Unit (YJPU), in consultation with the YJB, should seek secondary legislation to amend the YJB’s function to ‘monitor the operation of the youth justice system’ to ‘to promote and drive continuous improvement across the youth justice system’.
Justice & Legal
Keep Britain Working Review: Final report — Rec 2
Establish the Workplace Health Intelligence Unit – Quickly stand up and provide initial funding for the unit as an independent ‘movement HQ’ to support vanguards, build the evidence base and drive innovation. By 2029, it will deliver: • Outcome measures and data to underpin the Healthy Working Standard • Development …
Health & Social Care
Review of patient safety across the health and care landscape — Rec 2
CQC should remain the independent regulator and oversight body across the health and care system. However, it needs to adopt tailored approaches to assessments by sector and within sectors, taking into account the structure of commissioners (including private health insurers) and providers, as described in more detail in the previous …
Health & Social Care
Review of patient safety across the health and care landscape — Rec 1
A revamped, revitalised and reinforced NQB should be responsible for developing a comprehensive strategy to improve quality of care that is in line with the aims of DHSC and the NHS in England. This strategy should build on: This strategic approach should: More specifically, NQB should set out a vision …
Health & Social Care
Building Control Independent Panel — Rec 21
Bring together Departmental interests to issue a statement on the future of the CPS scheme. As part of that prioritise and support the BSR's plans to review 'conditions of authorisation'.
Building Safety
Building Control Independent Panel — Rec 20
Progress planned work to improve and regulate the warranty market. As part of that consider the issues raised with the panel about the approach to inspections and the impact on BC fees.
Building Safety
Building Control Independent Panel — Rec 17
Reduce OSR indicators to a concise set of no more than 20. Focus on inspection sufficiency, compliance, enforcement, competence and data quality to enable meaningful oversight.
Building Safety
Building Control Independent Panel — Rec 16
Reform the approach to measuring performance. Replace the current burdensome framework with a streamlined, outcome focused approach aligned to statutory purpose.
Building Safety
Building Control Independent Panel — Rec 14
Improve transparency and secure information sharing. Enable structured sharing of regulatory data between providers, the SCR, Government and the public to support accountability and risk based oversight.
Building Safety
Building Control Independent Panel — Rec 13
Establish national data standards and mandatory reporting. Ensure consistent, high-quality data on inspections, compliance, enforcement and outcomes across all providers. This includes automating data capture, improving consistency and strengthening real-time risk-based oversight.
Building Safety
Building Control Independent Panel — Rec 11
Extend compliance and stop notice powers to private sector RBCAs. Give all providers equivalent duties to act in the public interest, while retaining prosecution powers with new BCBs and the SCR.
Building Safety
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
Building Control Independent Panel — Rec 7
Consolidate and modernise statutory instruments. Remove contradictions, update outdated provisions and consolidate building regulations to create a coherent framework for all providers.
Building Safety
Building Control Independent Panel — Rec 6
Create one statutory process for applications, notices and approvals. Align requirements across all providers so the statutory function operates to the same clear and modernised rules.
Building Safety
Building Control Independent Panel — Rec 5
Strengthen national enforcement capability. Provide the SCR with specialist legal, investigatory and technical capacity to support robust and consistent enforcement across England.
Building Safety
Building Control Independent Panel — Rec 4
Define the role and powers of the Single Construction Regulator (SCR). Set out the SCR's remit across oversight, registration, performance monitoring, HRB decisions and enforcement.
Building Safety
Building Control Independent Panel — Rec 3
Create consolidated Building Control Bodies (BCBs). Establish fewer, larger building control bodies to take on statutory functions from LA BCAs, to deliver consistent decisions, risk-based inspections and enforcement.
Building Safety
Building Control Independent Panel — Rec 2
Remove dutyholder choice from statutory building control. End client selection of regulator and move to independent allocation model based on risk, competence and capacity. In transition to this, enable preference of BCB to be established.
Building Safety
Building Control Independent Panel — Rec 1
Establish a single, independent statutory building control system. Legislate for a unified statutory system for all non HRB work, built on independence, national consistency, clear duties and transparent public accountability.
Building Safety
Dash Patient Safety Review — Rec 2
Continue to rebuild the Care Quality Commission with a clear remit and responsibility. CQC should remain the principal independent regulator responsible for oversight of the health and care system. It should develop sector-specific approaches to registration and assessment, set standards for the quality of health and care in co-ordination with …
Health & Social Care
Accepted
Dash Patient Safety Review — Rec 1
Revamp, revitalise and significantly enhance the role of the National Quality Board. A revamped, revitalised and reinforced NQB should be responsible for developing a comprehensive strategy to improve quality of care that is in line with the aims of DHSC and the NHS in England. It should set out a …
Health & Social Care
Accepted
Fisher Review (Part 1) — Rec 18
There should be more stringent quality assurance regarding the delivery of disclosure learning by the College of Policing, Higher Education Institutions and other delivery partners. The results of these assessments should be shared with the National Police Chiefs' Council.
Justice & Legal
Owens Review — Rec 30
The Ministry of Justice and HMPPS to consider, with HMIP, whether RIE and unlawful detention should be part of the inspection regime.
Justice & Legal
Owens Review — Rec 29
The Ministry of Justice and HMPPS should review their internal audit capacity to provide assurance including direction against the prison performance framework.
Justice & Legal
Owens Review — Rec 28
Pending a fuller Criminal Justice System strategy, Government should revisit the performance framework for HMPPS and assure themselves it reflects their current priorities AND that well analysed data products exist to support it.
Justice & Legal
Owens Review — Rec 1
That HMPPS consider extending the use of body worn video to Operational Support Grade staff in public or prisoner facing roles.
Justice & Legal
Cunliffe Water Commission — Rec 82
Recommendation 82: The regulator, under its supervisory approach, should gain further assurance from companies in England and Wales on workforce and supply chains to ensure companies can sufficiently deliver.
Other
Cunliffe Water Commission — Rec 79
Recommendation 79: Under the supervisory approach, the regulator in England and Wales should provide assurance on how companies are delivering infrastructure spend.
Other
Cunliffe Water Commission — Rec 71
Recommendation 71: The regulator should be provided with stronger powers for the enforcement of existing security regulations in England and Wales.
Other
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 65
Recommendation 65: The regulator in England should continue the essential steps that Ofwat is taking to address issues with DPC and SIPR. A full evaluation of both schemes should be undertaken in 5 years when a broader evidence base has been accumulated. The Commission recognises that given different views on …
Other
Cunliffe Water Commission — Rec 61
Recommendation 61: The government and regulator in England and Wales should explore short-term measures to improve the functioning of the BRM.
Other
Cunliffe Water Commission — Rec 58
Recommendation 58: A formal turnaround regime should be established for the regulator in England and Wales to support turnaround of poorly performing companies. This should enable both an enhanced power of direction as well as regulatory forbearance.
Other
Cunliffe Water Commission — Rec 41
Recommendation 41 (England and Wales): The regulator should strengthen the C-Mex incentive to better reflect customer experience and move to a supervisory approach to monitoring the customer-focused licence condition.
Other
Cunliffe Water Commission — Rec 36
Recommendation 36: The Commission recommends the UK and Welsh governments improve regulatory oversight of water industry abstraction activity by bringing it under the Environmental Permitting Regime.
Other
Cunliffe Water Commission — Rec 35
Recommendation 35: The regulator, water industry and UK and Welsh governments should secure and expand Regulation 31 testing services for drinking water products.
Other
Cunliffe Water Commission — Rec 34
Recommendation 34: The UK and Welsh governments should introduce powers to strengthen the regulator's toolkit in relation to drinking water, including an extension of its powers to cover all third-party operators, and powers to directly impose financial penalties.
Other
Cunliffe Water Commission — Rec 33
Recommendation 33: The UK and Welsh governments should ensure an effective process is in place for regularly reviewing and updating drinking water standards.
Other
Cunliffe Water Commission — Rec 30
Recommendation 30: The regulator should significantly accelerate the implementation of digital programmes to support intelligence-led and transparent enforcement and compliance activities.
Other
Cunliffe Water Commission — Rec 27
Recommendation 27: The UK and Welsh governments should tighten regulatory oversight of sludge activity by moving the treatment, storage and use of sludge into the Environmental Permitting Regulations.
Other
Cunliffe Water Commission — Rec 26
Recommendation 26: The UK Government should review the approach to Continuous Water Quality Monitoring. This review should evaluate the effectiveness and value for money of these monitors, with a view to enhancing cost-efficiency through the adoption of technological advancements.
Other
Cunliffe Water Commission — Rec 25
Recommendation 25: The regulator in England and in Wales should significantly reform the system of Operator Self-Monitoring. It should develop a strengthened approach to monitoring, using greater digitisation, automation, public transparency, third party assurance and intelligence-led inspections.
Other
Cunliffe Water Commission — Rec 22
Recommendation 22: The regulator should review the performance incentives framework, to rationalise the overall number of PCs and make their corresponding ODI rewards, penalties and returns at risk, clear. This applies to England and Wales.
Other
PHSO casework decisions(8)
P-003058 — Care Quality Commission
Mr and Mrs B complained the CQC failed to properly inspect a nursing home, act on intelligence, communicate effectively, follow enforcement policy, and resolve their complaints, causing distress.
UK Government
Partly Upheld
Oct 2024
P-003045 — Care Quality Commission
A doctor complained the CQC failed to adequately address new evidence about her foster son's care or reconsider enforcement action after a coroner's inquest.
UK Government
Upheld
Aug 2024
P-003539 — Care Quality Commission
Mrs O complained the CQC failed to act against her daughter's college after inspections, did not inform her of risks, and neglected to prosecute based on evidence.
UK Government
May 2025
P-003487 — Care Quality Commission
Mrs X, on behalf of staff, complained about the CQC Inspector's unprofessional attitude and behaviour during an inspection, which negatively impacted staff confidence and sought service improvements.
UK Government
Apr 2025
P-004114 — Care Quality Commission
Miss A complained about significant delays by the CQC in issuing her business registration, requiring multiple applications. She stated these delays caused stress, mental health impact, and financial losses.
UK Government
Sep 2025
P-003503 — Hertfordshire and West Essex Integrated Care Board
Ms K complained the Organisation failed to oversee and respond to her concerns about her father's inadequate care by agency carers in a care home, leading to ongoing poor care.
NHS in England
Apr 2025
P-003511 — NHS England
Dr R complained NHS England's review panel improperly upheld a decision that his mother was ineligible for NHS Continuing Healthcare, despite her complex needs.
NHS in England
Apr 2025
P-003683 — York and Scarborough Teaching Hospitals NHS Foundation Trust
Miss A complained the Trust failed to investigate suspicious findings after her sister's hysterectomy or provide follow-up treatment, leading to her sister's death from cancer.
NHS in England
Partly Upheld
Jul 2025
LGO / SPSO decisions(35)
201400244 — Care Inspectorate
Ms C owns a childcare business. She initially set the business up with her daughter (Miss A) and registered the partnership with the Care Inspectorate. Miss A subsequently left the business and Ms C's son (Mr A) joined as her partner. This partnership change came to light during a routine …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Dec 2015
201202561 — Care Inspectorate
Miss C's mother had received care services through her local council for a number of years, but these were suddenly withdrawn. Miss C complained to the council and also asked the Care Inspectorate to investigate. The Care Inspectorate investigated four complaints about the council's termination of Miss C's mother's care …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Sep 2013
25-004-224 — Danforth Care No. 1 Limited
Summary: Ms X complained about poor service during her respite stay at Heatherton House, and the care provider’s failure to escalate her concerns. She left early due to the undue distress caused. Ms X received a partial refund for the unused days since making the complaint to us. The evidence …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
PSOW-202103154 — Meddyg Care Porthmadog
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
PSOW-202408904 — Welsh Government - Care Inspectorate Wales
Ms C complained that Care Inspectorate Wales had not acted impartially when it investigated and responded to her complaint. The Ombudsman decided that the Body’s investigation did not lack impartiality, but the response had not fully considered that there had been a breakdown in communication regarding the availability of training, …
PSOW (Public Services Om…
Mar 2025
21-009-703 — London Residential Healthcare Limited
Summary: The Care Provider acknowledged the care provided to Mrs Y was below an acceptable standard before the involvement of this office, but it did not offer an appropriate remedy for the injustice caused.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
24-019-026 — The Fremantle Trust
Summary: We will not investigate this complaint about the quality of care provided in a care home. This is because any injustice is insufficient to justify our involvement.
LGO (Local Government & …
Adult Care Services
Apr 2025
24-015-590 — North East Lincolnshire Council
Summary: We will not investigate this complaint about the quality of domiciliary care. The Council has refunded the cost of Mrs Y’s care and apologised to her daughter, Mrs X. Further investigation by us is unlikely to achieve anything more meaningful.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
202106302 — East Dunbartonshire Health and Social Care Partnership
C complained about the care provided to their elderly parent (A). A had to remain in bed to allow several pressure sores to be treated. To assist with moving A out of bed and changing A's position, a manual handling assessment was requested. C felt that there was an unreasonable …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Aug 2023
PSOW-202200031 — Plas Gwyn Nursing Home
Mrs X complained that she was unable to visit the Care Provider and had not received a response to her complaint. The Ombudsman was concerned that Mrs X had yet to receive a response to her concerns and contacted the Care Provider. As an alternative to an investigation, the Care …
PSOW (Public Services Om…
Health
Apr 2022
PSOW-202102997 — Betsi Cadwaladr University Health Board
Mr A, through his Community Health Council Advocate, complained about the care and treatment his father, Mr B, received at the Care Home. Mr B’s care needs meant he was in receipt of NHS Continuing Health Care (“NHSCHC”) from the Health Board who were responsible for monitoring the care provided …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
22-008-440 — Jubilee Court Care Ltd
Summary: We will not investigate this complaint about adult social care provision because the injustice claimed is not serious enough to warrant our involvement and the use of public money.
LGO (Local Government & …
Adult Care Services
Oct 2022
23-011-659 — Barchester Healthcare Homes Limited
Summary: Mrs X complains, on behalf of her father, Mr Y, Barchester Healthcare Homes Limited mishandled the pre-admission process and failed to ask relevant questions before her father moved into in the home. She says the Care Provider failed to engage with her or social services to complete a re-assessment. …
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2024
201508742 — Care Inspectorate
Mr C complained to us that the Care Inspectorate had published an inspection report on his nursery that was inaccurate. He stated that there were a large number of errors in both the draft report and the final published report. We found that although there had been errors in the …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
May 2017
25-011-335 — Care UK Care Services Limited
Summary: We will not investigate Ms X’s complaint about the residential care provided to her mother Ms Y.
LGO (Local Government & …
Adult Care Services
Jan 2026
24-023-387 — Sheffield City Council
Summary: I find fault in the care provided by a care provider acting on behalf of the Council. The Council has agreed to provide a remedy.
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-010-204 — Green Lane Care Centre
Summary: We cannot investigate this complaint as it is outside our jurisdiction. Mr X’s care was arranged and funded by the NHS and so the complaint can be investigated by the Health Services Ombudsman.
LGO (Local Government & …
Adult Care Services
Jan 2026
PSOW-202205658 — Cwm Taf Morgannwg University Health Board
Mr E complained about Cwm Taf Morgannwg University Health Board’s handling of his complaint about the care provided to his mother. The Ombudsman decided that the Health Board had failed to provide regular and meaningful updates and had not issued a complaint response to Mr E. She said that this …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202206173 — Cwm Taf Morgannwg University Health Board
Ms D complained that Cwm Taf Morgannwg University Health Board had failed to provide a complaint response to correspondence she sent to it in February 2022. The Ombudsman found that the Health Board had acknowledged Ms D’s letter but had failed to respond to it. She said that this caused …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202206233 — Betsi Cadwaladr University Health Board
Mrs A complained that the Health Board had failed to issue a complaint response to her in accordance with an agreement it had previously reached with the Ombudsman’s office (ref: 202204472). The complaint response should have been issued to Mrs A by 30 November 2022. The Ombudsman contacted the Health …
PSOW (Public Services Om…
Health
Dec 2022
PSOW-202105999 — Cwm Taf Morgannwg University Health Board
Miss A’s complaint related to the care and treatment that she received during her admission to Prince Charles Hospital in April 2021. Specifically, Miss A complained that she was inappropriately discharged on 22 April as she was not properly examined, such as with a speculum or an ultrasound, following the …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2022
PSOW-202108104 — Swansea Bay University Health Board
Mr A’s complaint centred on his care and management at Morriston Hospital (“the Hospital”). He complained that the Swansea Bay University Health Board (“the Health Board”) failed to accurately diagnose giant cell arteritis (“GCA” – inflammation in the lining of the arteries especially in the temple) and provide timely treatment …
PSOW (Public Services Om…
Health
Upheld
Feb 2023
PSOW-202206156 — Cardiff and Vale University Health Board
Mr C complained that Cardiff and Vale University Health Board had failed to adequately address his concerns about the care and treatment provided to his late father. The Ombudsman found that whilst the Health Board had issued a complaint response it had delayed making further contact with Mr C about …
PSOW (Public Services Om…
Health
Feb 2023
PSOW-202402334 — Estyn
Mr W complained about whether Estyn’s investigation into his complaint at Stage 2 of its complaints procedure was completed reasonably and in accordance with its ‘Complaint Handling Procedure 2021’. The Ombudsman found that Mr W’s complaint was not investigated in accordance with Estyn’s Complaint Handling Procedure 2021 which states that …
PSOW (Public Services Om…
Upheld
Jun 2025
22-002-226 — Liberty House Clinic Limited
Summary: We will not investigate this complaint about a Private Care Provider. This is because there is insufficient injustice caused to warrant our intervention. Also, some actions complained of fall outside of our jurisdiction as they do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Jun 2022
22-003-864 — Sunderland City Council
Summary: We will not investigate this complaint about the standard of care Mrs Y received in a nursing home. That is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Adult Care Services
Jul 2022
23-014-133a — Maria Mallaband Care Group Ltd (23 014 133a)
Summary: Mrs X complained about the treatment and care provided to her late grandmother, Mrs Y while she was living in a nursing home. We will not investigate Mrs X’s complaint because it is unlikely we could add to the responses she has already received from the organisations she complains …
LGO (Local Government & …
Health
May 2024
23-014-029 — Yourlife Management Services Limited
Summary: Ms X complains YourLife (Droitwich) failed to meet her father’s (Mr Y’s) needs when he went to live in Horton Mill Court in July 2021 and told his family he had to leave, resulting in him having to live in a care home and incurring losses selling his flat. …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
201103809 — Tayside NHS Board
Mr C complained that the board did not provide pelvic support girdles, which he considered his partner needed because of pelvic pain in pregnancy. We explained to him that our role in such complaints is limited because it is not for us to tell the NHS how to use their …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102661 — A Medical Practice in the Fife NHS Board …
Mr C complained that his GP practice decided to restrict the number of diabetic testing strips he could have, and then stopped providing them. He said that this was unfair and did not take into consideration his personal circumstances. Mr C said that self monitoring of his diabetes cannot be …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2012
201102066 — Care Inspectorate
Ms C, a childminder, complained about the Care Inspectorate’s decision to uphold a complaint that she did not have a safety net on a trampoline used by the children in her care. She said that this had not been pointed out on previous inspections. The law says that we cannot …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Partly Upheld
Jul 2012
201407618 — Care Inspectorate
Ms C complained to the Care Inspectorate about the care home her father was staying in. She complained about a range of issues, including how often bedding was changed, concerns about electric reclining chairs, and the lack of a care plan for her father. The Care Inspectorate responded to her …
SPSO (Scottish Public Se…
Scottish Government and Devolved Administration
Not Upheld
Aug 2015
PSOW-202308118 — Liberty Care Ltd
Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
21-010-477 — Sheffield City Council
Summary: I have ended our investigation into this complaint because the Council has recently begun an independent review of the care provider and service Ms X complained about. Further investigation by us could achieve nothing more.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jul 2022
21-018-997 — Assini Limited
Summary: We cannot investigate this complaint about the actions of a Private Care Provider. This is because the actions complained of fall outside of our jurisdiction to investigate as they do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Apr 2022
Domestic Homicide Reviews(1368)— showing 50 strongest matches
Tewkesbury — recommendation 17.8.2
A system of action tracking will be introduced to ensure that allocated actions are carried out and reviewed.
Gloucestershire Multi-Agency Risk Assessment Conference
Rotherham — recommendation 17.11
The Health and Well Being Board should commission a scrutiny review of domestic abuse support provision by cabinet members.
Health and Well Being Board
Rotherham — recommendation 17.10
DAPG should continue to pursue the development of a performance management framework
Safer Rotherham Partnership
Bury — recommendation 3
Review the current process for reviewing A&E attendances within health visiting PCFT
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Bury — recommendation 2.
The Head of the Public Protection Division to commission work to evaluate the effectiveness of the STRIVE programme, and consider its implementation with a structured and established police input into the process.
Greater Manchester Police
Greater Manchester Police
Portsmouth — recommendation 1
The Domestic Abuse Strategy Group will monitor a repeat audit for all single agency actions in twelve months to check all actions have been completed.
CSP
Portsmouth — recommendation 10
Although the IMR author has confirmed that the auditing of this new process will commence in Spring of 2022, the panel will further recommend that the Portsmouth Safeguarding Adult board will take responsibility to oversee this change.
Portsmouth Safeguarding Adults Board (PSAB)
Portsmouth — recommendation 8
Feedback to the CSP on the effectiveness of training related to domestic abuse, including the effectiveness of SafeLives DA Matters training.
Hampshire Constabulary
Hampshire and Isle of …
Portsmouth — recommendation 4
Audits of DA Safeguarding referrals for SCAS.
SCAS
South Central Ambulance Service …
Lincoln — recommendation i)
A monthly audit is undertaken of all safeguarding referrals completed by LCHS Urgent Treatment Centre staff to ensure all safeguarding procedures have been followed.
Lincolnshire Community Health Services
Lincolnshire Community Health Service …
Cheltenham — recommendation Probation.1
The Gloucestershire Probation Delivery Unit Quality Improvement Plan is revised to include learning from this DHR. The Probation Service aim is to deliver excellent services. We are working to improve the quality of work in domestic abuse cases: sentence management; assessments and reports.
Gloucestershire Probation Delivery Unit
Doncaster — recommendation 3
This will be evidenced by audit of the quality and volume of referrals in respect of domestic abuse.
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Portsmouth — recommendation 6
Operation Amberstone Lead may wish to audit investigation times to ensure investigations are being conducted diligently and expeditiously.
Hampshire & Isle of Wight Constabulary
Hampshire and Isle of …
Wokingham — recommendation R8
Feedback learning from this case within the RBFT to Oncology Clinical Governance, Planned Care Clinical Governance, Patient Experience Committee and Quality Assurance and Learning Committee.
Royal Berkshire NHS Foundation Trust
Royal Berkshire NHS Foundation …
Enfield — recommendation 2
Within 18 months, the Community Safety Partnership should evaluate whether complex cases are being managed more effectively
Community Safety Partnership
Enfield — recommendation 1
The key agencies within this review must consider how complex cases are managed and report back to the Community Safety Partnership and other senior level Boards by March 2018
key agencies within this review
Doncaster — recommendation 19.2.11
Review of procedures regarding the residents within Dioceses properties.
Sheffield Diocese
Tower Hamlets — recommendation 7.1.11
All recommendations to be added to the Multi-Agency Recommendations Action Plan.
Metropolitan Thames Valley Housing
Tower Hamlets — recommendation 7.1.8
Operational team meetings to have an item on required reporting compliance for violent & unexplained deaths.
Metropolitan Thames Valley Housing
Plymouth — recommendation 22
Safer Plymouth partner agencies should implement a quality assurance practice to ensure that information sharing processes between agencies are being adhered too.
Safer Plymouth partner agencies
Plymouth — recommendation 13
School 2 and 3 should review supervisory policies and practice in relation to DSL management.
School 2 | School 3
Warrington — recommendation 19.21
CGM CRC to develop and embed Quality Assurance and continuous improvement in relation to EMO arrangement.
Cheshire and Greater Manchester Community Rehabilitation …
Warrington — recommendation 19.17
WBC Adult Social Care to ensure that supervisors review each case when there is a transfer between case managers to maintain direction and focus.
WBC Adult Social Care
Warrington — recommendation 19.15
WBC Adult Social Care to undertake an audit of cases to confirm the effectiveness of recent strength-based approach training including the use of and clarity around service user outcomes.
WBC Adult Social Care
Warrington — recommendation 19.2
Warrington Community Safety Partnership should put in place processes by which it can gain assurance that. 1. MARAC actions are meaningful and contribute to the safety of the victim. 2. Agencies are held to account for the delivery of agreed actions. 3. Effective MARAC co-ordination arrangements are in place.
Warrington Community Safety Partnership
Lincoln — recommendation 8
The LSAB will need to seek assurance about: • The progress of the CCG’s work around the use of Learning Disability Health Reviews, the extent to which these reviews address mental capacity and they are making a difference to adults with care and support needs.
LSAB | ICB
Kent — recommendation 10
The measures put in place following the Serious Further Offences Review in April 2019 should be revisited to ensure these are being robustly applied. These measures should also be shared with the Ministry of Justice managing the transition of Community Rehabilitation Companies as they transition back into the National Probation …
KSS Community Rehabilitation Company
Kent — recommendation 8
The measures introduced following the Ofsted inspection in January 2019 of Front Door should be revisited to ensure there is compliance with a sharper focus on risk and urgency. An accompanying training needs analysis should be undertaken with Front Door staff. This may identify further areas of training that should …
Kent Children’s Social Services
Kent — recommendation 6
The Stalking SPOC initiative launched in July 2019 should be regularly reviewed to ensure best practice and lessons learned are identified at the earliest opportunity and disseminated to practitioners to enable them to deliver the best possible service to victims.
Kent Police
Kent Police
Coventry — recommendation 7.3.3
Quality assurance of the Responsible Officer’s enforcement action and decision making
Staffordshire and West Midlands Community Rehabilitation …
Probation Service
Coventry — recommendation 7.3.2
Dip sampling of Responsible Office’s case management/assessment records to ensure correct recording of factors linked to risk of harm
Staffordshire and West Midlands Community Rehabilitation …
Probation Service
Coventry — recommendation 7.3.1
Comprehensive and ongoing review of all practitioner referrals to interventions
Staffordshire and West Midlands Community Rehabilitation …
Probation Service
Kent — recommendation 6
That the NHS Trust, in light of the findings of their investigation, further consider whether the management and governance arrangements currently in place were effective and consider how lessons learnt from this review can be applied for the future.
NHS England
NHS England
Pembrokeshire — recommendation 21
Quality Assurance tools used across Primary Care to be revised and updated to ensure they are consistent with the Intercollegiate documents for child and adult safeguarding and the VAWDASV National Training Framework
Welsh Government
Welsh Government
Pembrokeshire — recommendation 12
The Safeguarding Team to audit the embedding of the WAST Ask and Act Policy in practice and report to the relevant Strategic Safeguarding Group
Welsh Ambulance Service NHS Trust
Welsh Ambulance Services NHS …
Pembrokeshire — recommendation 7
Primary Care to provide assurance that GP Practices have embedded the Mid and West Wales Regional Pathfinder for GPs based on the Safelives GP Pathfinder guidance
Hywel Dda University Health Board
Hywel Dda University Health …
Pembrokeshire — recommendation 6
Primary Care to improve compliance with Group 2 Ask and Act training and establish a mechanism for monitoring and reporting compliance
Hywel Dda University Health Board
Hywel Dda University Health …
Pembrokeshire — recommendation 5
The Corporate Safeguarding Team to audit the embedding of the Hywel Dda University Health Board’s Ask and Act Policy in practice and report to the Strategic Safeguarding Working Group
Hywel Dda University Health Board
Hywel Dda University Health …
Swindon — recommendation 15
Supervisors reviewing PPD1’s will be expected to make reference within the PPD1 to the decision taken not to arrest as part of their oversight into such matters, cognisant of the decision making process from the attending officer and the risks known at that time.
Wiltshire Police
Wiltshire Police
Oxford — recommendation 17
Thames Valley Police to carry out a review of property currently stored at Abingdon Police Station and a review of local management practices.
Thames Valley Police
Thames Valley Police
Oxford — recommendation 1a
To improve the monitoring of reduced timetables both at local authority and school levels.
Schools and Special Educational Needs
Oxford — recommendation EIS 1
Undertake an audit of practice and safeguarding focussing on quality of referral, assessment, planning, review and impact on outcomes.
Oxfordshire County Council Children’s Social Care …
Hillingdon — recommendation 4.6.7a
HIDVA to focus support on high risk cases and review repeat victims and audit to ensure the risk levels are being reduced.
Hillingdon IDVA
Hillingdon — recommendation 4.6.5b
Hillingdon CCG to oversee the implementation of NICE guidelines on Antisocial Personality Disorders: prevention and management, and to evaluate the effectiveness of local provision for people with personality disorders.
Hillingdon ICB
Hillingdon — recommendation 4.6.5a
Hillingdon CCG to provide assurance to SHP that CNWL’s action plan arising from the Internal Investigation Report has been implemented. The action plan will be monitored by the CCG using the Goodall Safeguarding meeting. An update on the action plan should be provided within six months of the DHR being …
Hillingdon ICB
Hillingdon — recommendation 4.6.3b
Metropolitan and Thames Valley Police to review the arrangements for ensuring that all relevant information is gathered before conducting arrest attempts in relation to domestic violence in another forces area. This should be subject to dip sampling to ensure compliance.
Metropolitan Police | Thames Valley Police
Metropolitan Police Service
Hillingdon — recommendation 4.6.3a
Metropolitan and Thames Valley Police to audit compliance with investigative expectations and supervision of allegations of domestic abuse.
Metropolitan Police | Thames Valley Police
Metropolitan Police Service
Hillingdon — recommendation 4.6.2b
Metropolitan Police to audit the effectiveness of arrangements for increasing the number of prosecutions using evidence based prosecutions.
Metropolitan Police
Metropolitan Police Service
Hillingdon — recommendation 4.6.2a
Metropolitan Police to audit the effectiveness of mechanisms in place to prioritise and actively pursue outstanding offenders of domestic abuse.
Metropolitan Police
Metropolitan Police Service
Hillingdon — recommendation 4.5.8
SHP to seek assurance from partner agencies that they are compliant with the NICE guidelines on domestic violence and abuse; multi agency working, by local agencies.
Safer Hillingdon Partnership (SHP)
CJINI inspection reports(82)showing 50 strongest matches
Review of the State Pathologist’s Department in Northern Ireland
State Pathologist's Department, Forensic Services
Jun 2005
Report on the Inspection of Forensic Science Northern Ireland
Forensic Science Northern Ireland, Forensic Services
Dec 2005
Inspection of the Compensation Agency (Northern Ireland)
Compensation Agency, Other Agencies and Organisations
Jan 2006
A review of Regulatory Agencies
Inspections and prosecutions by Departments and other bodie…
Jan 2006
Target setting and performance management in the Criminal Justice System
Governance, The Criminal Justice System
Jan 2006
Probation Board for Northern Ireland Corporate Governance
Probation Board for Northern Ireland (PBNI), Probation and …
Oct 2006
State Pathologist’s Department – A Follow-up Review
State Pathologist's Department, Forensic Services
Oct 2006
Summary of Criminal Justice Inspection Report Findings
Policing, Prisons
Feb 2010
A Follow-Up Review of inspection recommendations on the Royal Mail Group Crime Investigations function
Inspections and prosecutions by Departments and other bodie…
Jun 2010
An inspection of corporate governance arrangements within the Northern Ireland Prison Service
Prisons, Prison Operations and Management
Dec 2010
Enforcement in the Department of the Environment Northern Ireland: A Follow-Up Review of inspection recommendations
Inspections and prosecutions by Departments and other bodies
Nov 2011
Community Restorative Justice Ireland – A pre-accreditation inspection
Restorative Justice, Other Agencies and Organisations
May 2014
Resolve – A pre-accreditation inspection Report
Restorative Justice, Other Agencies and Organisations
Sep 2016
Report on an Unannounced Inspection of Magilligan Prison (12-22 June 2017)
Prisons, Magilligan Prison
Dec 2017
Report on an unannounced inspection of Maghaberry Prison (9-19 April 2018)
Maghaberry Prison, Prisons
Nov 2018
Report on an Unannounced Inspection of Hydebank Wood Secure College (23-24 October and 4-7 November 2019)
Prisons, Hydebank Wood Secure College
Jun 2020
Report on an Unannounced Inspection Ash House Women’s Prison Hydebank Wood (23-24 October and 4-7 November 2019)
Hydebank Wood Women’s Prison, Prisons
Jun 2020
An unannounced inspection of Magilligan Prison (21 May – 10 June 2021)
Prisons, Magilligan Prison
Feb 2022
Governance inspection of the Parole Commissioners for Northern Ireland
Parole Commissioners for Northern Ireland (PCNI), Probation…
Sep 2011
A Follow-Up inspection of Northern Ireland Prison Service mistaken prisoner releases
Prisons, Prison Operations and Management, Prisoner Rehabil…
Apr 2012
An inspection of Community supervision by the Probation Board for Northern Ireland
Probation Board for Northern Ireland (PBNI), Probation and …
May 2013
An inspection of the accuracy of Court Orders: Accuracy, Administration and Assurance
Prosecution and the Courts, Court Operations
Sep 2013
Follow-Up Review of the PPS response to strategic inspection recommendations made between 2013 and 2015
Public Prosecution Service for Northern Ireland (PPS), Pros…
Feb 2018
Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Jun 2018
Public Protection Inspection III: A thematic inspection of the public protection arrangements Northern Ireland
Risk Management and public protection arrangements, Probati…
Oct 2019
The Safety of Prisoners held by the Northern Ireland Prison Service
Prisons, Prisoner Safety
Nov 2019
An announced inspection of Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
Sep 2022
Northern Ireland Alternatives: Report of an inspection with a view to accreditation
Restorative Justice, Other Agencies and Organisations
May 2007
Report of an inspection with a view to accreditation under the Government’s Protocol for Community Based Restorative Justice
Restorative Justice, Other Agencies and Organisations
May 2007
Compensation Agency – Follow-Up Review
Compensation Agency, Other Agencies and Organisations
Jun 2007
An Inspection of the Public Prosecution Service for Northern Ireland
Public Prosecution Service for Northern Ireland (PPS), Pros…
Aug 2007
Forensic Science Northern Ireland: A Follow-Up Review of inspection recommendations
Forensic Science Northern Ireland, Forensic Services
Aug 2007
Scientific Support Services in the Police Service of Northern Ireland: A Follow-Up Review of Inspection Recommendations
Policing, Police Scientific Support
Aug 2007
The Office of the Police Ombudsman for Northern Ireland: A Follow-Up Review of the inspection recommendations
Policing, Police Ombudsman for Northern Ireland
Oct 2007
Enforcement in the Department of the Environment (DoE)
Inspections and prosecutions by Departments and other bodie…
Oct 2007
Community Restorative Justice Ireland pre-inspection of Schemes in Belfast and in the North West with a view to accreditation under the Government’s Protocol for Community Based Restorative Justice
Restorative Justice, Other Agencies and Organisations
Oct 2007
Report on the Inspection of the Youth Conference Service in Northern Ireland
Youth Justice and Intervention, Children and Young People
Feb 2008
An Inspection of the Belfast Harbour Police
Harbour and Airport Policing, Other Agencies and Organisati…
May 2008
Youth Justice Agency Woodlands Juvenile Justice Centre
Woodlands Juvenile
Justice Centre (Woodlands JJC), Children…
May 2008
Scientific Support Services in the Police Service of Northern Ireland: Second Follow-Up Review of inspection recommendations
Policing, Police Scientific Support
May 2008
Report of an announced inspection of Ash House Hydebank Wood (29 October – 2 November 2007)
Hydebank Wood Women’s Prison, Prisons
Jun 2008
Corporate Governance in the Youth Justice Agency of Northern Ireland
Youth Justice and Intervention, Children and Young People
Jun 2008
Community Restorative Justice Ireland – Report of an Inspection
Restorative Justice, Other Agencies and Organisations
Jun 2008
Hydebank Wood Young Offender Centre (5-9 November 2007)
Prisons, Hydebank Wood Secure College
Jul 2008
Inspection of Approved Premises
Probation and Public Safety, Approved Premises (Offender Ho…
Jul 2008
An inspection of the Royal Mail Group Crime Investigations Function
Inspections and prosecutions by Departments and other bodie…
Jul 2008
An inspection of the operation and effectiveness of Anti-Social Behaviour Orders (ASBOs)
Policing, Policing and the Community
Oct 2008
Policing with the Community – An inspection of Policing with the Community in Northern Ireland
Policing and the Community, Policing
Apr 2009
The Public Prosecution Service for Northern Ireland – A Follow-Up Review of the 2007 baseline inspection report recommendations
Public Prosecution Service for Northern Ireland (PPS), Pros…
Jun 2009
Inspection of Forensic Science Northern Ireland
Forensic Science Northern Ireland, Forensic Services
Jul 2009
DSA service inquiries(30)
Service Inquiry into death of a Royal Marine during an endurance march on Dartmoor Training Area on 28 May 2015
The Service Inquiry report into the death of a Royal Marine while conducting officer training at Commando Training Centre, Royal Marines Lympstone.
Land
Mar 2016
Service Inquiry into the Watchkeeper (WK031) Unmanned Air Vehicle (UAV) accident at West Wales Airport on 16 October 2014
The report of the Service Inquiry following the Watchkeeper (WK031) Unmanned Air Vehicle (UAV) accident at West Wales Airport.
Aviation
Aug 2016
Service Inquiry into death of a serviceman from 5 Rifles in Paderborn, Germany on 18 June 2015
The report of the Service Inquiry following the death of a serviceman during an annual fitness test, near Alanbrooke Barracks, Paderborn, Germany.
Other
Aug 2016
Service Inquiry into the Watchkeeper (WK006) Unmanned Air Vehicle (UAV) accident at Boscombe Down Aerodrome on 2 November 2015
The report of the Service Inquiry following the Watchkeeper (WK006) Unmanned Air Vehicle (UAV) accident at Boscombe Down Aerodrome.
Aviation
Dec 2016
Service Inquiry into an accident involving a Puma HC MK 2 (XW229) in Kabul, Afghanistan on 11 October 2015
Service Inquiry into the Puma HC Mk2 accident at Headquarters Resolute Support, Kabul, in which five people died when the aircraft struck a tethered surveillance balloon cable on approach.
Aviation
Dec 2016
Service Inquiry into the death of a soldier whilst parachuting at Bad Lippspringe, Germany, on 29 September 2015
The Service Inquiry report into the death of a soldier during an Adventurous Training expedition to Rhine Army Parachute Association (RAPA) in Bad Lippspringe, Germany.
Aviation
Apr 2017
Service Inquiry into the aircraft accident involving YAK52 G-YAKB on 8 July 2016
The report of the Service Inquiry following the YAK52 G-YAKB aircraft accident close to Boscombe Down, Wiltshire
Aviation
Jun 2017
Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013
The releasable extracts of the Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013.
Land
Apr 2017
Service Inquiry into the death of a soldier participating in live fire tactical training at Heely Dodd Range, Otterburn on 22 August 2016
The report of the Service Inquiry following the death of a soldier participating in live fire tactical training at Heely Dodd Range, Otterburn on 22 August 2016.
Other
Nov 2017
Service Inquiry report into the Challenger 2 incident at Castlemartin Ranges, Pembrokeshire on 14 June 2017
The Service Inquiry report into the Challenger 2 incident at Castlemartin Ranges, Pembrokeshire on 14 June 2017.
Other
Jul 2018
Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area on 1 November 2016.
The Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area on 1 November 2016.
Weapons & Ordnance
Aug 2018
The Non-Statutory Inquiry (NSI) report into a RAF BLSA Luge accident at Igls Austria on 29 January 2018
A Non-Statutory Inquiry (NSI) has been carried out into a RAF BLSA Luge accident at Igls Austria on 29 January 2018.
Aviation
Sep 2018
Service Inquiry report into the Loss of Watchkeeper (WK043) Unmanned Air Vehicle over Cardigan Bay in West Wales on 24 March 2017
The Service Inquiry report into the loss of Watchkeeper (WK043) unmanned air vehicle over Cardigan Bay in West Wales on 24 March 2017.
Aviation
Apr 2019
Service Inquiry report into the Loss of Watchkeeper (WK042) Unmanned Air Vehicle over Cardigan Bay in West Wales on 3 February 2017
The Service Inquiry report into the loss of Watchkeeper (WK042) unmanned air vehicle over Cardigan Bay in West Wales on 3 February 2017.
Aviation
Apr 2019
Service Inquiry into the accident involving HAWK T Mk1A XX204 on 20 March 2018
A service inquiry report into the accident involving HAWK T Mk1A XX204 on 20 March 2018.
Aviation
Oct 2019
Service Inquiry into the death of a soldier from a gunshot wound at Camp Taji, Iraq on 2 January 2017
Service Inquiry into the death of a soldier from a gunshot wound at Camp Taji, Iraq on 2 January 2017.
Weapons & Ordnance
Nov 2019
Service Inquiry into the death of a soldier following an animal attack at Liwonde National Park, Malawi on 5 May 2019
Service Inquiry into the death of a soldier following an animal attack at Liwonde National Park, Malawi on 5 May 2019.
Other
Oct 2020
Service Inquiry report into the death of a soldier during an annual fitness test at Brecon on 19 July 2016
The Service Inquiry report into the death of a soldier during an annual fitness test at Brecon on 19 July 2016.
Land
Nov 2017
Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area
The Service Inquiry report into the death of a soldier of the Scottish and Northern Irish Yeomanry during an accident involving a Jackal vehicle on Catterick training area on 29 January 2019.
Land
Jan 2021
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood on 16 November 2020
Maritime
Mar 2022
Service Inquiry into the Loss of Hawk T Mk1 XX189 from 736 Naval Air Squadron, RNAS Culdrose
Service Inquiry into the loss of a Hawk T1 of 736 Naval Air Squadron from RNAS Culdrose; both aircrew ejected and the aircraft was destroyed.
Aviation
Jul 2022
Service Inquiry into the alleged exposure of UK Defence Personnel to asbestos during overseas exercises and training since 2018
Service Inquiry into the alleged exposure of UK Defence Personnel to asbestos during overseas exercises and training since 2018.
Land
Aug 2022
Service Inquiry investigating the accident involving F-35B ZM152 on HMS Queen Elizabeth on 17 November 2021 - Interim Report
Interim Report from the Service Inquiry investigating the accident involving F-35B ZM152 on HMS Queen Elizabeth on 17 November 2021.
Aviation
Sep 2022
Service Inquiry into the loss of F-35B Lightning ZM152 (BK-18)
Service Inquiry into the loss of an F-35B Lightning of 617 Squadron, embarked on HMS Queen Elizabeth, which crashed into the Mediterranean during take-off; the pilot ejected safely.
Aviation
Aug 2023
Service Inquiry into the fatal accident involving a Scimitar Fighting Vehicle on Salisbury Plain Training Area - 15 October 2021
Service Inquiry into the fatal accident involving a Scimitar Fighting Vehicle on Salisbury Plain Training Area - 15 October 2021.
Land
Nov 2023
Service Inquiry into the death of a soldier from 23 Parachute Engineer Regiment at MOD Woodbridge, July 2022
Service Inquiry report into the death of a soldier from 23 Parachute Engineer Regiment at MOD Woodbridge in July 2022.
Aviation
Feb 2024
Service Inquiry into the fatal collapse of a service person while undertaking a run in Sennelager, Germany, on 16 January 2023
The Service Inquiry report into the fatal collapse of a service person while undertaking a run in Sennelager, Germany, on 16 January 2023.
Other
Jul 2024
Service Inquiry into the death of a service person during an adventurous training expedition to Stubai Glacier, Austria on 11 March 2023
The Service Inquiry report into the death of a service person during an adventurous training expedition to Stubai Glacier, Austria on 11 March 2023.
Land
Mar 2025
Service Inquiry into the accident involving Red Arrows Hawk T Mk1 XX179 near Bournemouth
Service Inquiry into the death of Red Arrows pilot Flight Lieutenant Jon Egging, whose Hawk T1 crashed near Bournemouth following a display.
Aviation
Dec 2012
Service Inquiry into the accident involving Hawk T Mk1 XX177 at RAF Scampton
Service Inquiry into the death of Red Arrows pilot Flight Lieutenant Sean Cunningham, who was fatally injured when his ejection seat initiated while the Hawk T1 was stationary at RAF Scampton and the main parachute did not deploy.
Aviation
Feb 2014
CQC enforcement actions(74)showing 50 strongest matches
Criminal Prosecution: The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust
The Care Quality Commission prosecuted The Queen Elizabeth Hospital King's Lynn NHS Foundation Trust, which was fined £60,000 after pleading guilty to not providing safe care and treatment. This exposed a patient to significant risk of avoidable harm due to …
Dec 2022
Criminal Prosecution: University Hospitals of Derby and Burton NHS Foundation Trust
The Care Quality Commission brought a prosecution against University Hospitals of Derby and Burton NHS Foundation Trust. The trust pleaded guilty to failing to provide safe care and treatment to a patient, causing them avoidable harm. Following a sentencing hearing, …
Mar 2023
Warning Notice: West London NHS Trust
CQC told West London NHS Trust to make improvements to its community-based mental health services following an inspection in May. The inspection found significant staffing issues and delays to people accessing treatment, which put some people at risk of harm. …
Jul 2022
Conditions Imposed: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission placed conditions on University Hospitals Birmingham NHS Foundation Trust's registration. This action followed inspections where the trust had not met the requirements of a previous warning notice and further issues were identified. Conditions were also imposed …
Feb 2024
Warning Notice: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission (CQC) served University Hospitals Birmingham NHS Foundation Trust with a warning notice following inspections carried out in December. CQC found that the trust needed to make significant and immediate improvements to its staffing levels in medical …
Good Hope Hospital
Apr 2023
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) conducted an inspection of inpatient wards for people with a learning disability or autistic people at Lanchester Road Hospital and Bankfields Court, operated by Tees, Esk and Wear Valleys NHS Foundation Trust. Following the inspection, …
Lanchester Road Hospital in Durham and Bankfields…
Oct 2022
Warning Notice: Nottinghamshire Healthcare NHS Foundation Trust
The Care Quality Commission (CQC) issued requirement notices to Nottinghamshire Healthcare NHS Foundation Trust following inspections from October to December last year. CQC found improvements were needed in the trust's acute wards for adults of working age and psychiatric intensive …
Mar 2024
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) found improvement is needed in the children and young people’s (CYP) services run by Kettering General Hospital NHS Foundation Trust, after an inspection in December. Due to concerns found at this inspection, CQC has taken …
Kettering General Hospital
Apr 2023
Warning Notice: Kent and Medway NHS and Social Care Partnership Trust
The Care Quality Commission issued a warning notice to Kent and Medway NHS and Social Care Partnership Trust, telling it to make urgent improvements. This followed an inspection in March which found a decline in the quality of care provided, …
Oct 2025
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission (CQC) took enforcement action, serving Greater Manchester Mental Health NHS Foundation Trust with two Section 29A warning notices. One notice related to ligature and fire risks, and the other to staffing and governance, requiring significant improvements …
Nov 2022
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued Gloucestershire Hospitals NHS Foundation Trust with a warning notice following an inspection of its surgical services. The inspection was undertaken in response to concerns received about the safety and quality of the services, including …
Cheltenham General Hospital and Gloucestershire R…
Oct 2022
Warning Notice: Cheshire and Wirral Partnership NHS Foundation Trust
The Care Quality Commission (CQC) served Cheshire and Wirral Partnership NHS Foundation Trust with a warning notice following an inspection in November. The inspection found acute wards for adults of working age and psychiatric intensive care units to be inadequate. …
Mulberry ward in Macclesfield and Brooklands and …
Feb 2023
Warning Notice: Leeds and York Partnership NHS Foundation Trust
The Care Quality Commission (CQC) re-rated the long stay or rehabilitation mental health wards for working age adults, run by Leeds and York Partnership NHS Foundation Trust, as requires improvement. Following an inspection on 10 and 11 March, CQC found …
Asket Croft, Asket House and Newsam Centre Ward
Jul 2026
Warning Notice: Surrey and Sussex Healthcare NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Surrey and Sussex Healthcare NHS Trust following an inspection in November last year. CQC found a breach of regulations relating to how the trust is managed and downgraded its leadership …
Jul 2026
Conditions Imposed: Greater Manchester Mental Health NHS Foundation Trust
The Care Quality Commission imposed conditions on Greater Manchester Mental Health NHS Foundation Trust following an unannounced inspection in March 2024. The conditions require the trust to make improvements in specific areas, including effective service management, ensuring a clean, smoke-free …
Acute wards for adults of working age and psychia…
Dec 2024
Criminal Prosecution: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission brought a prosecution against Shrewsbury and Telford Hospital NHS Trust, which was ordered to pay a total of £1,375,712 after pleading guilty to failing to provide safe care and treatment to two patients, causing them avoidable …
Royal Shrewsbury Hospital
May 2022
Conditions Imposed: Mid and South Essex NHS Foundation Trust
The Care Quality Commission (CQC) placed conditions on Basildon University Hospital’s registration following inspections of its medical care and urgent and emergency services between December 2024 and March 2025. CQC found serious overcrowding in the emergency department, risking people’s safety, …
Basildon University Hospital
Oct 2025
Warning Notice: Countess of Chester Hospital NHS Foundation Trust
The Care Quality Commission rated Countess of Chester Hospital NHS Foundation Trust as 'requires improvement' and took enforcement action following an inspection in February and March. CQC served the trust with two warning notices, requiring urgent improvements in the effectiveness …
Jun 2022
Conditions Imposed: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission imposed conditions on Tees, Esk and Wear Valleys NHS Foundation Trust's registration in August 2019. This action followed an inspection of the trust’s child and adolescent mental health wards (CAMHS) in June 2019, which were rated …
Aug 2019
Warning Notice: Surrey and Borders NHS Foundation Trust
The Care Quality Commission told Surrey and Borders NHS Foundation Trust it must make improvements to its acute wards for adults of working age and psychiatric intensive care units to keep patients safe. CQC highlighted serious concerns surrounding patient safety …
Abraham Cowley Unit
Sep 2020
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: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) told Kettering General Hospital NHS Foundation Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection in March 2013 which found that standards relating to …
Kettering, Northamptonshire
May 2013
Warning Notice: Plymouth Hospitals NHS Trust
The Care Quality Commission issued a formal warning to Plymouth Hospitals NHS Trust, requiring urgent improvements to protect patients undergoing surgery at Derriford Hospital. This action followed an unannounced inspection where the trust did not meet five national standards, including …
Derriford Hospital
Jul 2013
Warning Notice: University Hospitals Sussex NHS Foundation Trust
The Care Quality Commission (CQC) carried out an unannounced focused inspection of University Hospitals Sussex NHS Foundation Trust's maternity and surgical services during September and October 2021, in response to concerns about safety and quality. Following the inspection, CQC issued …
Dec 2021
Warning Notice: University Hospitals Bristol and Weston NHS Foundation Trust
The Care Quality Commission inspected the medical care services department at Weston General Hospital and found that the leadership team needed to make a number of sustainable improvements. CQC told the trust that it must send an action plan outlining …
Weston General Hospital
May 2021
Warning Notice: South London and Maudsley NHS Foundation Trust
The Care Quality Commission (CQC) has told South London and Maudsley NHS Foundation Trust that it must make urgent improvements to the quality of one of its acute wards for adults of working age and psychiatric intensive care units (PICU). …
Jim Birley Unit, Maudsley Hospital
Mar 2021
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: London North West University Healthcare NHS Trust
The Care Quality Commission (CQC) conducted an unannounced focused inspection of the maternity service at Northwick Park Hospital in April 2021, in response to information of concern. Following the inspection, CQC told London North West University Healthcare NHS Trust that …
Northwick Park Hospital
Jun 2021
Urgent Enforcement Action: Sheffield Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) took urgent action following an unannounced focused inspection of maternity services at the Jessop Wing. Urgent conditions were imposed on the trust requiring them to take action to ensure the safety of patients using these …
Jessop Wing
Jun 2021
Urgent Enforcement Action: Nottingham University Hospitals NHS Trust
Following inspections on 14 and 15 October 2020, CQC imposed conditions on the registration of maternity and midwifery services at Nottingham City Hospital and Queen’s Medical Centre under Section 31 of the Health and Social Care Act 2008. This urgent …
Nottingham City Hospital and Queen’s Medical Cent…
Dec 2020
Other: Basildon and Thurrock University Hospitals NHS Foundation Trust
The Care Quality Commission took action at Basildon and Thurrock University Hospitals NHS Foundation Trust. This decision followed an inspection which revealed serious concerns regarding standards at Basildon University Hospital.
Nov 2012
Warning Notice: North Cumbria Integrated Care NHS Foundation Trust
The Care Quality Commission (CQC) told North Cumbria Integrated Care NHS Foundation Trust that it must make immediate improvements to keep people safe following inspections in August and September. CQC issued the trust with a warning notice for Cumberland Infirmary …
Cumberland Infirmary and West Cumberland Hospital
Nov 2020
Warning Notice: Luton and Dunstable Hospital NHS Foundation Trust
CQC inspectors found that Luton and Dunstable Hospital NHS Foundation Trust was failing to meet a number of essential standards of care for patients. CQC raised immediate concerns with the trust, demanding that identified problems be addressed and requiring the …
May 2011
Warning Notice: East Sussex Hospitals NHS Trust
CQC inspectors found East Sussex Hospitals NHS Trust was failing to meet a number of essential standards of care for patients following a review in February 2011. CQC raised immediate concerns with the trust's chief executive, demanding that the trust …
May 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
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC has told County Durham and Darlington NHS Foundation Trust that it must make immediate improvements to the quality and safety of care it’s providing, and has downgraded its well-led rating from good to inadequate following an inspection from 2 …
Dec 2025
Warning Notice: Tameside Hospital NHS Foundation Trust
The Care Quality Commission reviewed information and visited the trust on 9 March 2011, finding that care was falling short of essential standards in three areas, including safe and appropriate care and meeting individual dietary needs. CQC is requiring Tameside …
May 2011
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: United Lincolnshire NHS Trust
Following a visit to Pilgrim Hospital, the Care Quality Commission found United Lincolnshire NHS Trust was not taking appropriate steps to ensure people receive effective, safe and appropriate care. Inspectors noted that care plans did not always reflect patient needs, …
Pilgrim Hospital
Mar 2011
Warning Notice: Plymouth Hospitals NHS Trust
Following a visit to Derriford Hospital, the Care Quality Commission found that important check-lists recommended by the World Health Organisation and the National Patient Safety Agency were not being used effectively by surgical teams. The CQC required Plymouth Hospitals NHS …
Derriford Hospital
Feb 2011
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission (CQC) has told Mid Essex Hospital Services NHS Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection at Broomfield Hospital in Chelmsford, Essex, which found …
Broomfield Hospital, Chelmsford, Essex
May 2013
Warning Notice: University Hospitals Plymouth NHS Trust
The Care Quality Commission (CQC) issued University Hospitals Plymouth NHS Trust with a warning notice following an inspection of Derriford Hospital's urgent and emergency care department in March. CQC found that the trust must make significant and immediate improvements, outlining …
Derriford Hospital's urgent and emergency care de…
May 2021
Conditions Imposed: Portsmouth Hospitals NHS Trust
The Care Quality Commission issued a Warning Notice to Portsmouth Hospitals NHS Trust, requiring improvements in safety, patient consent, dignity and respect, safeguarding, and overall leadership. Concurrently, CQC placed six conditions on the trust's registration, mandating specific actions to ensure …
Queen Alexandra Hospital
Aug 2017
Warning Notice: Central and North West London NHS Foundation Trust
The Care Quality Commission formally warned Central and North West London NHS Foundation Trust that it must improve the care it provides at the Campbell Centre, Milton Keynes, and 3 Beatrice Place, Kensington. At the Campbell Centre, warning notices were …
Campbell Centre, Milton Keynes and 3 Beatrice Pla…
Mar 2014
Warning Notice: Sheffield Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Sheffield Teaching Hospitals NHS Foundation Trust following an inspection in October and November. The inspection found deterioration in the quality of services, leading to the trust's overall rating dropping to …
Apr 2022
Warning Notice: Salisbury NHS Foundation Trust
The Care Quality Commission (CQC) told Salisbury NHS Foundation Trust that improvements needed to be made in its maternity and spinal services at Salisbury District Hospital following an inspection on 31 March 2021. CQC found that governance arrangements were not …
Salisbury District Hospital
Jul 2021
Warning Notice: Royal Cornwall Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Royal Cornwall Hospitals NHS Trust following an announced inspection in December. The inspection assessed actions taken after seven 'never events' occurred within the trust's surgical care group and emergency department. …
Feb 2021
Warning Notice: Nottingham University Hospital NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Nottingham University Hospital NHS Trust following an inspection in June and July. CQC found areas where improvements were needed, particularly around leadership, risk management, governance, and culture. Concerns included a …
Sep 2021
Urgent Enforcement Action: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission (CQC) took urgent action following a focused inspection of children and young people ext{
The Princess Royal Hospital in Telford
Apr 2021
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) served Tees, Esk and Wear Valleys NHS Foundation Trust a section 29A warning notice following an unannounced focused inspection in January. Inspectors found concerns that urgently needed addressing, including risks not being assessed effectively or …
Mar 2021
MNSI reports(2)
Safety spotlight: Reviewing and actioning laboratory test results
Safety spotlight on the review and actioning of laboratory test results in maternity care.
Themed Review
May 2025
MNSI Annual Report and Recommendations 2024/25
Annual report of the Maternity and Newborn Safety Investigations programme. MNSI progressed 618 investigations in 2024/25 and made 1,122 safety recommendations to 126 organisations. The programme has completed more than 4,000 investigations to date and works with all 120 trusts …
Annual Report