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 17 independent accountability sources, so the source mix matters as much as the headline total.
441 inquiry recs
95 PFD reports
406 committee recs
244 HSSIB recs
810 CQC actions
8 ICIBI recs
6 PPO recs
16 IOPC recs
16 NAO recs
5 PHSO recs
8 IMB recs
2 IMB reports
94 Scottish FAIs
12 detention investigation recs
8 PHSO decisions
35 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(441)— showing 50 strongest matches
64 — Welsh independent school standards update
Recommendation: The Welsh Government should: update the Independent School Standards as a matter of urgency; update the national minimum standards for boarding schools as a matter of urgency; legislate so that all residential special schools are judged against the quality standards …
Gov response: On 30 June 2022, the Welsh Government stated that it will amend and strengthen the independent school regulations, and that work is ongoing to draft the legislation. The Welsh Government also stated that it will …
Accepted
60 — Independent school governance standards
Recommendation: The Department for Education and the Welsh Government should: amend the Independent School Standards to include the requirements that there is an effective system of governance, based on three principles of openness to external scrutiny, transparency and honesty within the …
Gov response: On 30 June 2022, the UK government stated that it agreed with the first two points of the recommendation in principle. It stated that it intended to consult on revised Independent School Standards in 2023 …
Accepted in Part
58 — Residential schools inspection and guardians registration
Recommendation: The Department for Education and the Welsh Government should: require all residential special schools to be inspected against the quality standards used to regulate children's homes in England and care homes in Wales; reintroduce a duty on boarding schools and …
Gov response: On 30 June 2022, the UK government stated that it was still of the view that the best way to protect children in residential special schools was to strengthen the National Minimum Standards (NMS), and …
Accepted in Part
50 — Independent validation of Catholic audit programme
Recommendation: The Catholic Safeguarding Advisory Service should have the effectiveness of its audit programme regularly validated by an independent organisation which is external to the Church. These independent reports should be published.
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the Catholic Safeguarding Standards Agency (CSSA) Board is committed to the independent verification of its audit processes, and would undertake a formal process …
Accepted
49 — Catholic non-compliance framework
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a clear framework for dealing with cases of non-compliance with safeguarding policies and procedures. That framework should identify who is responsible for dealing with issues …
Gov response: On 30 September 2021, the Catholic Council for the Inquiry stated that the trustee bodies of all Catholic dioceses and religious orders were invited to subscribe to the Catholic Safeguarding Standards Agency. The Catholic Safeguarding …
Accepted
47 — Catholic lead clergy for safeguarding
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious in England and in Wales should each nominate a lead member of the clergy for safeguarding to provide leadership and oversight on safeguarding matters to their respective …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that the role description for the Lead Bishop for the Catholic Bishops' Conference of England and Wales was approved and Bishop Paul Mason was …
Accepted
46 — Church independent external safeguarding audits
Recommendation: The Church in Wales should introduce independent external auditing of its safeguarding policies and procedures, as well as the effectiveness of safeguarding practice in dioceses, cathedrals and other Church organisations. Audits should be conducted regularly and reports should be published. …
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it remained committed to their programme of five-yearly independent audits. The joint …
Accepted
FR-2 — Child Protection Authorities
Recommendation: The Inquiry recommends that the UK government establishes a Child Protection Authority for England and the Welsh Government establishes a Child Protection Authority for Wales. Each Authority's purpose should be to: improve practice in child protection; provide advice and make …
Gov response: We accept the need for a stronger safeguarding system. We will ensure the relevant actions included within our reform programme, Stable Homes, Built on Love, fulfil this recommendation.
Accepted in Part
7 — Catholic complaints policy with escalation process
Recommendation: The Catholic Bishops' Conference of England and Wales and the Conference of Religious should publish a national policy for complaints about the way in which a safeguarding case is handled. The policy should deal with communication with complainants during the …
Gov response: On 30 April 2021, the Catholic Council for the Inquiry stated that a framework and template for complaints was ratified by the Bishops. The framework and template include the need for clear communication between the …
Accepted
AFA-7B — Cancer Services
Recommendation: The Trust has worked through a detailed action plan relating to Cancer Services, specifically in relation to the oversight and support for MDTs and has addressed the issues identified in the SAIs in urology. Extending the work to include dimensions …
Response Pending
AFA-7A — Urology Service
Recommendation: The impact of the Inquiry on the Urology Department has been very significant. The Inquiry recommends that the Urology Service be provided with ongoing specific medical and operational leadership support from Senior Management, the Board and the Department. This will …
Response Pending
AFA-6 — Medical leadership and doctors in difficulty
Recommendation: The Inquiry recommends that: • There must be sustained investment in leadership development for doctors at all career stages. Improvements discussed in the Medical Management and Leadership chapter should continue. The Department should establish a dedicated regional programme to strengthen …
Response Pending
AFA-3 — Board and senior leadership development
Recommendation: The Inquiry recommends: • The Department implements and funds a bespoke, regional leadership development programme for Board members and senior leaders, co-designed with external expertise including specific training in patient safety. This will complement the recently updated Board Handbook which …
Response Pending
R103 — Public learning disability performance dashboard within 12 months
Recommendation: A live dashboard of performance, quality and safety indicators within learning disabilities must be developed and made publicly available within 12 months of the publication of this report.
Response Pending
R84 — Learning disability service culture measure
Recommendation: RQIA needs to consider adopting a measure of service culture specific to learning disability services for use in its inspections. Such measures have already been developed for learning disability residential settings.
Response Pending
R83 — RQIA use of CCTV in inspections
Recommendation: The RQIA needs to reconsider whether to make use of CCTV when it is in operation in a service it is inspecting where concerns have been raised.
Response Pending
R82 — Risk-based inspection prediction
Recommendation: RQIA should consider developing a risk-based way of predicting which services are in difficulty. It is well known that certain aspects of services tend to be associated with abuse: service users who are vulnerable, who have few communication skills; service …
Response Pending
R81 — Expert clinical governance advisory function
Recommendation: The DoH should establish an expert clinical/social governance advisory function to support providers.
Response Pending
R79 — Board member learning framework
Recommendation: The DoH should commission the HSC Leadership Centre to develop a learning framework for all Board members. All Trust Board directors should be required to undertake an examined course in governance (including both financial and clinical/social care governance, including patient …
Response Pending
R78 — Audit committee implementation tracking
Recommendation: HSCT Board audit committees should consider all internal audit recommendations and require directorates to provide updates on implementation three months, six months and one year after the internal audit report is received, and three monthly thereafter if still not fully …
Response Pending
R77 — Triennial Board governance reviews
Recommendation: The DoH Permanent Secretary should commission triennial reviews of each Board’s collective performance in clinical and social care governance.
Response Pending
R76 — NED with clinical governance expertise
Recommendation: NEDs should be selected for their expertise across a range of skills and at least one should have extensive experience of clinical or social care governance and be appointed as a senior independent director with that responsibility. The DoH should …
Response Pending
R75 — Executive Director of Clinical and Social Care Governance
Recommendation: There must be understanding of both individual untoward events but also (and more importantly) systems and trends. Creating and maintaining effective governance for complex systems requires specialist skills. While this is largely recognised within finance governance, only superficial consideration is …
Response Pending
R67 — Independent review of systemic abuse conditions
Recommendation: Where there is evidence or suspicion of widespread abuse involving multiple staff and residents, focusing solely on individual perpetrators is insufficient. An independent review of enabling conditions should be conducted separately from case-specific or PSNI investigations. This review must be …
Response Pending
R66 — Quarterly safeguarding file audit
Recommendation: A quarterly multidisciplinary audit of 10% of safeguarding files per ward or residential unit should be conducted. Findings must be integrated with incident data and reported to the Executive Team, NEDs and the Strategic Planning and Performance Group (SPPG).
Response Pending
R64 — Safeguarding dashboard with screening decisions
Recommendation: The dashboard should include the number of allegations reported, together with the screening decision (referral to the Adult Safeguarding Gateway, referral to the joint protocol or no further action). Particular scrutiny should be given to allegations of abuse by staff …
Response Pending
R62 — Monthly safeguarding dashboard
Recommendation: Metrics on both child and adult safeguarding processes should be reported monthly via a safeguarding dashboard, with the same visibility and status as monitoring elective surgery or emergency department waiting times. These metrics should be publicly available.
Response Pending
R48 — Holistic safeguarding governance review
Recommendation: HSCTs must review and improve governance of safeguarding to ensure that findings from different safeguarding investigations are considered holistically, synthesised and presented to the public part of a Board-level committee.
Response Pending
R45 — Incident trend analysis on board dashboards
Recommendation: Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s quality and safety dashboard. In private and third sector care …
Response Pending
R44 — Proactive quality assurance beyond complaints
Recommendation: Complaints alone are a poor indicator of quality of care, particularly in a vulnerable population such as those admitted to MAH. A low volume or absence of complaints does not necessarily indicate that care provided is good or satisfactory. Organisations …
Response Pending
R43 — Red-rated complaints shared with all NEDs
Recommendation: All complaints managed at corporate level and rated as red (using the red, amber and green (RAG) rating matrix) should be shared with all non-executive directors (NEDs) on the Board.
Response Pending
R36 — Seclusion as extraordinary intervention with serious event audit
Recommendation: Use of seclusion should be considered an extraordinary and exceptional intervention. Each intervention should be subject to a serious event audit, conducted by a professional outside the service provider’s learning disabilities services. This audit should be shared with the person’s …
Response Pending
R33 — Statistical process control charts
Recommendation: To ensure meaningful interpretation of these trends, all HSCTs should adopt statistical process control (SPC) charts, as developed by Walter Shewhart in 1939. SPC charts use calculated upper and lower control limits to distinguish between normal variation in a stable …
Response Pending
R32 — Balanced performance measures including restrictive practices
Recommendation: HSCTs should implement a comprehensive set of balanced performance measures across all services for people with learning disabilities, including those commissioned from third-party providers. These measures should include: Trends in the use of restrictive practices; Trends of aggressive behaviour incidents, …
Response Pending
R30 — NED champion for restraint reduction
Recommendation: HSCTs should appoint a non-executive director (NED) to act as a champion for restraint reduction, with a mandate to hold executive directors accountable for delivery.
Response Pending
R28 — Restraint Reduction Network principles
Recommendation: The Restraint Reduction Network identifies six principles to avoid the use of restrictive practice. While there is evidence that some Trusts have adopted these principles, further action is needed to ensure the principles are fully embedded. These principles must be …
Response Pending
R27 — RQIA assurance of property processes
Recommendation: RQIA should examine the provider organisation’s internal assurance processes and make recommendations where they are insufficient.
Response Pending
R23 — Regular property and finance compliance checks
Recommendation: All organisations taking responsibility for property and/or finance for people with learning disabilities and autistic people should institute regular checks of adherence to their policies. This includes local checks, corporate checks and periodic internal audit checks.
Response Pending
R15 — Independent care plan reviews
Recommendation: Care plans should be regularly evaluated to assess their impact on people’s wellbeing. This is the responsibility of the care team and should include formal, documented input from the service user themselves (where appropriate) and families. Additionally, there should be …
Response Pending
R14 — Restraint and seclusion observation records
Recommendation: Observation records detailing all use of restraint and seclusion should be completed by the individual observing. In HSCT facilities, if the observer is unregistered, a registered staff member should countersign the entry rather than create a second-hand record. In private …
Response Pending
R3 — Non-acceptance notification within three months
Recommendation: With the exception of Recommendations 88 and 89 (R88 & R89) any other organisation that does not accept a recommendation for which it is named as responsible, should write within three months of this report to the DoH Permanent Secretary …
Response Pending
R2 — Public acceptance of recommendations within six months
Recommendation: The DoH should indicate publicly within six months of this report which recommendations it accepts and those it does not accept (and why). This should include the recommendations for all organisations for which the DoH holds primary responsibility. In relation …
Response Pending
R1 — Implementation monitoring group
Recommendation: The implementation of the following recommendations should be monitored by the DoH and progress should be reported to the DoH Permanent Secretary. To ensure progress is made, an implementation consultation group, which should include service users and the relatives of …
Response Pending
MACP-5 — Apply OFSTED-like standards to Police Service inspections for improved quality and reporting
Recommendation: That principles and standards similar to those of the Office for Standards in Education (OFSTED) be applied to inspections of Police Services, in order to improve standards of achievement and quality of policing through regular inspection, public reporting, and informed …
Unknown
MACP-3 — Grant Her Majesty's Inspectors full powers to inspect all Police Services.
Recommendation: That Her Majesty's Inspectors of Constabulary (HMIC) be granted full and unfettered powers and duties to inspect all parts of Police Services including the Metropolitan Police Service.
Unknown
BRIS-73 — Grant Council powers to enforce good regulation principles and consistent professional body behaviour
Recommendation: The Council for the Regulation of Healthcare Professionals should have formal powers to require bodies which regulate the separate groups of healthcare professionals to conform to principles of good regulation. It should act as a source of guidance and of …
Unknown
BRIS-72 — Prioritise establishing statutory Council for Regulation of Healthcare Professionals with broad membership
Recommendation: The Council for the Regulation of Healthcare Professionals should be established as a matter of priority. It should have a statutory basis. It should report to Parliament. It should have a broadly-based membership, consisting of representatives of the bodies which …
Unknown
BRIS-71 — Establish a single body to coordinate all healthcare professional regulatory bodies
Recommendation: In addition, a single body should be charged with the overall co-ordination of the various professional bodies and with integrating the various systems of regulation. It should be called the Council for the Regulation of Healthcare Professionals. (In effect, this …
Unknown
BRIS-70 — Establish single regulatory bodies for each distinct healthcare professional group
Recommendation: For each group of healthcare professionals (doctors, nurses and midwives, the professions allied to medicine, and managers) there should be one body charged with overseeing all aspects relating to the regulation of professional life: education, registration, training, CPD, revalidation and …
Unknown
HIDD-39 — Urgently introduce independent monitoring and auditing for all safety-related work
Recommendation: BR shall introduce monitoring and independent auditing systems in all safety-related aspects of work, in particular the S&T Departments, with the greatest urgency, in advance of Total Quality Management as an aid to good management.
Unknown
Prevention of Future Deaths reports(95)— showing 50 strongest matches
Walter Gordon Powley
Concerns: Uncovered, excessively hot pipes and radiator valves in a care home posed a burn risk. This was compounded by a lack of specific room risk assessments and oversight failures by regulatory bodies.
Response (CQC): The CQC acknowledges the incident and will share the report's findings within the organisation. They are exploring ways to work more closely with the HSE and ensuring their new inspection …
Response (Health Safety Executive): HSE will raise concerns about assessing risks from hot surfaces and pipe-work at the next GB Social Care Partners Forum meeting, scheduled for February 2014. They will also share the …
Response (RNHA): The RNHA acknowledges the risk and states they regularly advise members of their responsibilities under the Health & Safety at Work Act, particularly regarding covering radiator pipes. They will continue …
Responded
Kathleen Rosemary Dixon
Concerns: Repeated critical incidents in the Trust, evident across multiple inquests, necessitate an independent assessment of its operations.
Response (Department of Health): The Department of Health acknowledges the concerns raised about mental health assessments at Cumbria Partnership NHS Foundation Trust and outlines existing measures and guidance in place to improve patient safety …
Overdue
Mary Waldron
Concerns: Nursing home staff failed to recognise and act on an acutely unwell resident due to inadequate ongoing training and poor internal investigation. Communication issues during ambulance transfer also posed a risk.
Overdue
Derrick Rivers
Concerns: The care home had an inadequate, unspecific drugs administration protocol and lacked audit processes, with management unaware of non-compliance. Regulatory bodies also failed to identify these critical issues during inspections.
Overdue
Clive Clinton
Concerns: A care home's complaints procedure failed, preventing family concerns about poor care (e.g., hygiene, medication) from reaching senior management and placing residents at risk of harm.
Overdue
Peter White
Concerns: Early Warning Observation Charts were incorrectly completed, triggers ignored, and observations unchecked by qualified staff, leading to missed opportunities for critical interventions. No audit system was in place for chart accuracy.
Overdue
Ryan Loughran, Katie Joyce, Muhanna Alhayany and Sophie Ryan-Palmer
Concerns: Deficient governance and lack of a national lead for autologous stem cell transplants, coupled with absent national benchmarking data and inaccessible international trial results, hinder optimal patient care.
Response (NHS England): NHS England is reviewing service specifications, establishing a national expert group for oncology, enhancing reporting to the BSBMT registry, and commissioning its quality surveillance team to assure changes in governance.
Responded
Edwin Thompson
Concerns: A clear, concise directive is needed for care home staff to promptly seek medical advice for residents experiencing pain, especially if it suggests a cardiac issue.
Overdue
Huseyin Erdogan
Concerns: Key action plans developed following a death, with a November 2014 completion date, remained largely unimplemented by the time of the inquest, raising concerns about preventing future deaths.
Overdue
Maurice Cowling
Concerns: Despite the rarity of deaths from certain medical procedures, three fatalities occurred within a short period, two within the Trust, indicating a potential systemic issue.
Response (Northern Lincolnshire Goole NHS Trust): The Trust conducted a patient safety review of three cases and concluded that the complications were managed appropriately and existing arrangements are adequate. They state no further specific actions have …
Responded
Kathleen Neville
Concerns: The absence of a Medication Reconciliation policy allowed medication errors to go undetected for too long, posing a significant risk of future deaths, particularly in other Health Boards without such a policy.
Overdue
Amanda Ellams
Concerns: Substandard medical record-keeping, inadequate oxygen saturation monitoring, unsafe patient discharge, and a "flawed" unanswered out-of-hours district nursing telephone system collectively contributed to significant care failures.
Response (Response Alexandra Hospital): The hospital-wide completion of training on documentation and legal aspects for patient records was 95%, and further documentation training has been scheduled; nursing staff will be notified that nursing notes …
Overdue
Adrian Smith
Concerns: A clear instruction for an MRI scan from a specialist hospital was not followed by staff at another hospital, highlighting a lack of systems to ensure specialist advice is implemented.
Response: The Trust will change the communication process for specialist radiological investigation queries by having the consultant radiologist speak directly with the senior neurosurgeon. A standard operating procedure (SOP) will be …
Overdue
Angela Brealey
Concerns: The trust lacked clear procedures for handling third-party information, showed minimal multidisciplinary team involvement in patient care, and its serious incident review process failed to identify several treatment concerns.
Response (South Staffordshire and Shropshire Healthcare NHS Trust): The Trust has reviewed and amended its Serious Incident Review process and now employs a full-time Serious Incident Review Co-ordinator and Administrator. Reports now go through an additional governance process, …
Overdue
Harry Gill
Concerns: The NHS 111 vomiting pathways were not robust, leading to inappropriate responses in most calls and failing to ensure adequate patient care.
Response (NHS England): NHS Pathways has amended the vomiting questions to be more specific, focusing on the nature of the vomit and the presence of coffee ground-like material. They have also enhanced the …
Responded
Martyn Watkins
Concerns: Concerns highlight a need for thorough review of the Trust's care, and for the CQC to ensure all deficiencies in care and facility safety on Aspen Ward are identified and addressed.
Response (CQC): The Trust had learnt from the death and implemented changes to manage future risks on Aspen Ward, though details of changes not provided in this extract.
Overdue
Norman Beard
Concerns: Poor management, staff shortages, and lack of policies contributed to neglected pressure ulcers and significant weight loss. Delayed specialist referrals and ignored medical advice compounded the patient's deteriorating condition.
Overdue
Barry Thompson
Concerns: The patient's high-priority triage was not followed by timely review by a doctor or antibiotic administration per national standards, the NEWS score was not actioned, and there were issues managing a diabetic patient's monitoring and basic needs, along with inaccurate and incomplete record-keeping.
Overdue
Helen Millard
Concerns: The "traffic light" ligature risk classification system in psychiatric facilities is flawed; all ligature points, regardless of height, pose an extreme risk and should be categorized as "red" for urgent elimination.
Overdue
Doreen Willis
Concerns: Concerns relate to key learning points from a Root Cause Analysis report on care homes, urging the CQC to review its inspection practices in light of these findings.
Response (Torbay and South Devon NHS Trust): The trust summarises the key learning outcomes from the agency review, pertaining to medicine management policies and processes for care homes. It references NICE guidance and the Electronic Transfer of …
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR …
Response (CQC): The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend …
Response (NHS England): NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next …
Responded
David Lindsey
Concerns: The family contended that the trust did not follow NICE guidelines for cancer screening, referrals, diagnosis and treatment, and that the trust did not follow its own policies and guidelines.
Overdue
Brian Betterton
Concerns: Product recalls for items like fuse boxes are ineffective because end-users are often untraceable, as professional purchasers are not required to log installation locations or end-user details.
Response (Department for Business Energy Industrial Strategy): The Department for Business, Energy & Industrial Strategy set up the Working Group on Product Recalls and Safety in October 2016, which published recommendations on improving recalls and reducing fires …
Responded
Sarah Kiff
Concerns: GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.
Response (Stonefield Street Surgery): The practice has produced annual audit reports around new cancer diagnoses for several years; the practice has a new written policy around methodology for undertaking HVS and the recording of …
Responded
Elaine Bradbrook
Concerns: Multiple failures in escalating care for a deteriorating patient, inadequate risk reduction during transfer, and lack of internal investigation or learning by the trust contributed to serious concerns.
Response (United Lincolnshire Hospitals NHS Trust): United Lincolnshire Hospitals NHS Trust acknowledges communication issues and historical problems with their Serious Incident (SI) process. They have made significant improvements to the SI process in the last 12 …
Responded
David Sketchley
Concerns: The investigation into a patient's death was inadequate, failing to determine supervision levels, collaborate with manufacturers, identify incident cause, or properly assess equipment suitability.
Response: The CQC is gathering evidence into this matter with a view to deciding whether there has been a failure by BUPA and/or the Registered Manager to comply with the Health …
Overdue
Neville Welton
Concerns: The Health Board demonstrates persistent delays in completing serious incident reviews and implementing action plans, leaving safety measures outstanding for too long.
Response: The Health Board is establishing weekly meetings for senior staff to review incidents, track progress of investigations, and ensure timely action plan implementation, commencing July 12th, 2018. They will also …
Overdue
Lewis Colgan
Concerns: Inadequate supervision of care coordinators, incompatible caseloads, and staff changes compromised mental health care continuity and engagement. Lack of robust processes for CPA meetings and an incomplete Root Cause Analysis further raised concerns.
Overdue
Ester Wood
Concerns: Ongoing, systemic problems with ambulance delays, emergency department access, and patient flow continue to place lives at risk, despite repeated prior warnings.
Overdue
Margaret Evans
Concerns: Persistent issues with ambulance delays, emergency department overcrowding, and resource availability continue to pose significant risks to patient safety.
Overdue
Ruth Whitmore
Concerns: Issues included unclear responsibility and lack of awareness for nurses in charge, coupled with an inadequate initial investigation into an incident, which failed to thoroughly interview staff or analyse events.
Overdue
Sophie Bennett
Concerns: The care home suffered from inadequate governance, untrained and insufficient staff, poor record-keeping, and ill-conceived changes that negatively impacted residents. Board oversight was grossly inadequate.
Overdue
Tom Cribley
Concerns: Repeated systemic failings included poor documentation, delayed escalation of patient deterioration and NMEWS, inadequate clinical handovers, and delayed administration of crucial antibiotics for sepsis, issues previously identified by CQC.
Overdue
Jean Cutler
Concerns: The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.
Response (Cole Valley Nursing Home): New, comprehensive Falls Risk Assessments (FRAs) for all residents have been introduced and completed, considering internal and external risk factors. A new competent, experienced and dynamic manager who will provide …
Responded
Kathleen Smith
Concerns: Care home staff lacked sufficient training in first aid for choking, assisting residents, and preparing appropriate foods for those with swallowing difficulties, compounded by inadequate management oversight.
Response (Coed Duon Care Home): Coed Duon Care Home has implemented several changes, including SALT training for staff, designation of two Dysphagia champions, creation of a diets and fluids consistency file for each resident in …
Responded
Daniel Williams
Concerns: Deficient fundamental nursing care on a general ward led to patient deterioration, exacerbated by a flawed C-diff infection investigation process that failed to examine initial care failures on the transferring ward.
Response (Guys and St Thomas NHS Trust): The Trust's C-diff Action Group reviewed the Trust's C-diff investigation process and revised it to include a stage to check whether the mandatory infection control data forms need to be …
Responded
Ben Haddon-Cave
Concerns: Railway fence inspection failures, exacerbated by dense vegetation and inadequate viewing practices, alongside systemic flaws in dual inspection reporting, led to a lack of oversight and repair.
Response (Network Rail): • A National Safety Bulletin will be issued to all Off Track teams, which are the Network Rail maintenance teams that carry out boundary inspections. • The National Safety Bulletin …
Responded
Pamela Evans
Concerns: Nurses had a fundamental misunderstanding of when to call the critical care outreach team, compounded by a lack of audit, limited CCOT authority, incorrect NEWS scoring, and the Trust's failure to identify these issues.
Response (Bedford Hospital NHS Trust): Bedford Hospital NHS Trust will ensure assessments and patient observations are carried out. The post falls protocols and level of escalation will be reviewed and there will be Shared learning …
Responded
Evelyn Swift
Concerns: The medical group lacked safe procedures for triaging patients, allocating home visits, providing urgent clinical advice, documenting calls, and ensuring sufficient clinical capacity; they also lacked processes to review significant events and learn from them.
Overdue
Gillian McKinlay
Concerns: There was no clear responsibility for A&E patients' overall care, and mandated clinical reviews for high EWS scores did not occur or were escalated. The Trust's serious incident investigation was inadequate, failing to address key issues or audit improvements.
Overdue
Frank Medley
Concerns: The Trust had an ineffectual system for detecting adverse outcomes, seriously deficient case reviews, and failures in sepsis pathway activation and expediting critical scans.
Response (Royal Blackburn Teaching Hospital): Royal Blackburn Teaching Hospital has established a core group to oversee implementation of an action plan addressing concerns regarding detection of adverse outcomes, review of the case, and radiology practices, …
Responded
Elizabeth Robinson
Concerns: Inadequate nursing staff levels and an unreviewed internal investigation meant nurses were unable to deliver safe care, assess patient fall risk correctly, and were unaware of learning opportunities.
Response (Aneurin Bevan University Health Board): Aneurin Bevan University Health Board has established a Ysbyty Ystrad Fawr (YYF) Health Care Support Worker (HCSW) pool in September 2020 to support enhanced care levels. The Corporate Serious Incident …
Responded
Rachel Johnston
Concerns: The care home failed to adequately investigate nurse failings or report them to the NMC for over two years, and lacked proper policies for identifying, investigating, or suspending staff misconduct.
Response (Holmleigh Care Homes Ltd): Following a death, the care home introduced training for all nurses and reviewed its policies. They have since implemented the Staff Retention policy to ensure agency workers under investigation do …
Overdue
Pauline Brumfitt
Concerns: The care home failed to implement existing falls risk assessment policies, missing opportunities to prevent multiple falls and neglecting timely reporting or investigation of incidents.
Response (Anchor Hanover Group): Anchor Hanover Group has reviewed and updated training, policies and procedures, introduced more formal triage arrangements, additional handover guidance, and improvements to Care Quality Indicators.
Overdue
Kyle Hurst
Concerns: The Health Board failed to implement a beneficial medical protocol and delayed approving critical risk mitigation procedures for diagnostic results, despite setting their own deadlines, thereby putting lives at risk.
Response (BCUHB): BCUHB is considering adopting the SNAP protocol for paracetamol overdose treatment but requires local review and approval. The Health Board is reviewing historic action plans from serious incident investigations and …
Responded
Susan Merton
Concerns: The Health Board consistently fails to implement its own action plan recommendations and address concerns within set timeframes, leading to ongoing risks to patient lives.
Response (BCUHB): BCUHB changed its serious incident process in April 2021, requiring all investigation reports to be submitted for scrutiny and approval at an Incident Learning Panel. The Health Board is tracking …
Overdue
Philip Ellis
Concerns: The deceased was able to leave service premises unsupervised and obtain drugs in breach of rules, with no serious incident review conducted into these supervision failures.
Response (Free the Way): Free the Way has introduced measures including escorting clients returning from relapse to collect belongings, searching all property, and restricting unaccompanied leave. Clients entering treatment will be monitored closely and …
Responded
Emma Burbury
Concerns: There was a missed opportunity to caseload a dual diagnosis patient, alongside systemic communication issues between agencies regarding record access. Patients were also discharged too readily for missed appointments without considering other support services.
Response (Cornwall Partnership): The Trust is contributing to the implementation of a system-wide Dual Diagnosis policy and will explore improvements to information sharing between partner organisations. Community Mental Health transformation work is underway …
Response (NHS Kernow Clinical Commissioning Group): NHS Kernow will provide funding for read-only access to We Are With You (WAWY) notes for CMHT staff at CFT. They are engaging with CFT regarding discharge processes and will …
Responded
Darrell Devlin
Concerns: Over-reliance on remote drug and alcohol service contacts without in-person assessments or drug testing led to inaccurate client assessment, risking harm from excessive dosage or polydrug exposure.
Response (Humankinds): Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of …
Response (Greater Manchester Mental Health NHS Foundation Trust): Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, …
Responded
Rebecca Begg
Concerns: The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Response (Heathcotes Group): Full incident reviews are implemented and the Clinical team now has involvement to understand the root cause and offer different support methods. The internal governance and quality assurance procedures have …
Overdue
Select committee recommendations(406)— showing 50 strongest matches
#53 —
Recommendation: In the short term, the Ministry of Justice should reform the Legal Aid Agency’s objectives and delegated authorities so that it is responsible not only for processing applications and controlling error, but also for monitoring legal need, identifying unmet demand …
Response Pending
#51 —
Recommendation: Despite being the body tasked with administering the legal aid scheme, the Legal Aid Agency is ill-equipped to ensure its service provision is sufficient to meet demand. Existing research on legal aid demand and coverage is entirely sourced from independent …
Response Pending
#50 —
Recommendation: The organisational set-up of the Legal Aid Agency remains deficient in delivering access to justice. The objectives of the Legal Aid Agency are construed narrowly and relate to improving processing times and reducing error. There is an insufficient focus on …
Response Pending
#31 —
Recommendation: We welcome the government’s decision to remove the need for local authorities to seek approval from the Secretary of State before establishing selective licensing schemes. The government needs to go further to remove further barriers that inhibit the uptake and …
Response Pending
#30 —
Recommendation: Selective licensing remains a useful tool that local authorities can use to proactively target enforcement activity at areas with the poorest housing conditions. The new Private Rented Sector Database has the potential to complement selective licensing by helping local authorities …
Response Pending
#27 —
Recommendation: The government must conduct and publish a full assessment of the resources and powers currently available to local authorities to regulate and enforce standards in the private rented sector, including the new duties placed on local authorities under the Renters …
Response Pending
#25 —
Recommendation: The government must require councils to publish annual reports on the regulation and enforcement of their local private rented markets, including information on their inspection and enforcement activity. Doing so will enable better scrutiny and accountability of local authorities’ activities …
Response Pending
#24 —
Recommendation: We are disappointed to hear a postcode lottery of local authority regulation and enforcement of standards in the private rented sector has persisted for many years. Far too many local authorities are failing to protect tenants and provide a meaningful …
Response Pending
#22 —
Recommendation: The government must ensure that the private rented sector database provides a useful tool to educate and better inform landlords about their role and responsibilities and encourage them to adopt more professional practices. The database must include information and guidance …
Response Pending
#7 —
Recommendation: We recommend that the new Private Rented Sector Database allows private landlords to self-declare that their properties comply with the new Decent Homes Standard at the earliest opportunity. Using the database in this way would allow landlords who already comply …
Response Pending
#6 —
Recommendation: The new Private Rented Sector Database provides a useful mechanism for landlords to proactively demonstrate that their properties comply with existing and upcoming standards, including the Decent Homes Standard. This is not a substitute for strong, proactive enforcement. However, we …
Response Pending
#5 —
Recommendation: We recommend that the government place a duty on local authorities to take enforcement action against any breach of the new Decent Homes Standard, not just breaches of Criterion A. This will act as a stronger incentive for landlords to …
Response Pending
#4 —
Recommendation: The effectiveness of the government’s plans to apply the Decent Homes Standard to the private rented sector rests on how effectively local authorities enforce this standard. We are disappointed that the government only plans to place a duty on local …
Response Pending
#3 —
Recommendation: We welcome the government’s decision to apply the new Decent Homes Standard to privately rented homes. The government has a difficult balance to strike between the need to deliver better homes to tenants quickly while allowing landlords the time they …
Response Pending
#3 —
Recommendation: We welcome the programme’s devolved design and recognise the government’s view that it appropriately balances national oversight with local flexibility. We are reassured that extensive performance monitoring is part of CtW, and that there is also a comprehensive evaluation programme …
Response Pending
#51 —
Recommendation: GBE and other public buyers must ensure that solar procurement decisions are made on the basis of independent assessments and not rely solely on the SSI to provide assurance of supply chains. (Recommendation, Paragraph 256)
Gov response: The Government welcomes the work of the Solar Stewardship Initiative (SSI) in promoting transparency and accountability within the solar supply chain through the use of assessments driven by independent audits. However, procurement decisions are not …
Position Not Stated
#35 —
Recommendation: Enabling full cross-border enforcement will only be effective if licensing authorities have the capacity and incentives to undertake it. The government should address the current mismatch between enforcement responsibilities and funding by enabling licensing authorities to recover the costs of …
Response Pending
#34 —
Recommendation: We welcome the minister’s statement that the government wants licensing authorities to be able to take enforcement action against all the taxis and PHVs operating in their area. We look forward to the government’s forthcoming legislation setting out a clear …
Response Pending
#33 —
Recommendation: Many licensing authorities lack the resources and capacity to carry out effective enforcement. Enforcement officers are not able to take action against all taxi and private hire activity in their area. Cooperation between licensing authorities can be a positive step …
Response Pending
#32 —
Recommendation: The introduction of national standards should be accompanied by a single national complaints and incident reporting portal for taxi and private hire services. It should be digitally inclusive, route reports to the responsible authority, and include clear service standards for …
Response Pending
#31 —
Recommendation: Complaints and incident reporting arrangements are fragmented. In some areas they are difficult for passengers and drivers to navigate, reducing transparency and weakening accountability. (Conclusion, Paragraph 112)
Response Pending
#22 —
Recommendation: National standards should set a clear benchmark for licensing processing times, covering applications, renewals and variations, and require all licensing authorities to publish performance against that benchmark in a consistent format. (Recommendation, Paragraph 86)
Response Pending
#19 —
Recommendation: We recognise that mandating in-vehicle CCTV across the sector would be a significant, and in some quarters, controversial step. However, we heard substantial evidence about its potential to strengthen safety for both passengers and drivers, and we consider that evidence …
Response Pending
#10 —
Recommendation: The overwhelming majority of drivers uphold high standards and play an essential role in keeping communities moving safely. However, the system needs to provide a robust safety net for the protection of passengers and drivers. Safety standards must be absolute …
Response Pending
#5 —
Recommendation: The government’s proposal to move responsibility for licensing to local transport authorities may have advantages in terms of improving operational capacity, and the ability of transport authorities to better integrate taxis into their transport plans and brand accordingly. However, we …
Response Pending
#4 —
Recommendation: We urge the department to bring forward a clear plan to curtail the extensive practice of out-of-area working and create greater incentives for drivers to license in the locality in which they operate. This will enable local licensing authorities to …
Response Pending
#3 —
Recommendation: Out-of-area working is now a widespread feature of the taxi and private hire vehicle market. We recognise the strength of concern about its impact on standards, local accountability and public confidence. We also acknowledge that outright prohibition would be impractical. …
Response Pending
#2 —
Recommendation: We are pleased that the government has set out plans for legislation to modernise and consolidate the licensing framework for taxis and private hire vehicles. We urge the government to use the Law Commission’s 2014 draft bill and the report …
Response Pending
#24 —
Recommendation: The Department acknowledged that it had prioritised throughput— processing cases quickly—at the expense of consistent decision-making. With hindsight, that had been the wrong thing to do. It had been done for the right reasons—because the Department wanted to get the …
Response Pending
#22 —
Recommendation: In the written evidence we received, people described opaque and inconsistent decision-making, painting a picture of an arbitrary and unreliable system. They stated that support was reduced or removed without a clear rationale, change in need, and sometimes without warning. …
Response Pending
#26 —
Recommendation: The Government should seek to provide a joined-up subsea cables function providing a centralised point of contact for industry and international partners. This body should co-ordinate, not duplicate, cross-government work—bringing together departments and agencies covering subsea infrastructure operations, policy, security, …
Gov response: The Government partially agrees with this recommendation. We agree with the Committee on the importance of a centralised, cross-government function to support coordination on subsea cable security policy. However, we do not think that expanding …
Accepted
#41 —
Recommendation: His Majesty’s Inspectorate of Prisons is responsible for inspecting the conditions and treatment of prisoners in England and Wales, with one of their inspection ‘expectations’ explicitly highlighting the importance of prisoners interacting with staff who are able to implement culturally …
Response Pending
#21 —
Recommendation: The Department told us it is developing an ‘Ajax 2’ package of upgrades, including composite rubber tracks and automatic track tensioners, as a technical solution which would reduce the need for soldiers undertaking the maintenance checks. These modifications are intended …
Response Pending
#20 —
Recommendation: The Department told us that it had no safety concerns about Ajax provided it was operated and maintained correctly within its design parameters. It then asserted that the incident during the exercise occurred because the vehicles had not been operated …
Response Pending
#19 —
Recommendation: The Department said that for our soldiers to develop and maintain the skills they require to operate on armoured vehicles, it needs to get them back on those vehicles as quickly as possible. However, it asserted that the safety of …
Response Pending
#18 —
Recommendation: Our predecessor Committee first reported on the failings of the Ajax programme in June 2022. It was told that the Army’s trials team had first raised concerns about vibrations in late 2019, and the Department rightly described it as “unforgivable” …
Response Pending
#20 —
Recommendation: NHSE informed us that there are also a number of broader developments which may affect service provision for frailty including a forthcoming modern service framework, new funding models for ICBs, a frailty improvement collaborative involving seven sites around the country, …
Response Pending
#19 —
Recommendation: NHSE informed us that it was establishing a national frailty dashboard which will take into account the range of interventions that NHSE expects ICBs to have in place. It noted that it does not intend to publish what it considered …
Response Pending
#14 —
Recommendation: NHSE also told us that it was about to write to ICBs, as part of the framework for neighbourhood health, with the key requirements that ICBs need to have in place next year around enabling better, more appropriate care for …
Response Pending
#13 —
Recommendation: NHSE told us that it is working to improve accountability and that, in the future, it intends to hold ICBs to account for commissioning against the modern service framework and expects there will be data from its national frailty dashboard …
Response Pending
#12 —
Recommendation: NHSE has set requirements for ICBs and GPs to provide health services that aim to assess and support people living with moderate and severe frailty.25 NHSE considers that ICBs are responsible for managing and measuring performance of many of the …
Response Pending
#6 —
Recommendation: We remain deeply concerned that cuts to ICBs are insufficiently thought through and will undermine their ability and capacity to carry out their functions. It is unclear what oversight roles ICBs will retain under NHSE’s plans to make them into …
Gov response: The government agrees with the Committee’s recommendation. consider risk appetite and tolerance for programmes in the current net zero R&I portfolio as set out in the Delivery Plan and develop an overall government risk appetite …
Response Pending
#19 —
Recommendation: The final bill must include provisions to establish a new, independent public body as the Regulator for property managing agents, with enforcement powers. This must include powers for the Regulator to issue fines or revoke licences of managing agents who …
Response Pending
#55 —
Recommendation: The Home Office should conduct a full review of its management of Covid-19 impacts on asylum accommodation and immigration detention in conjunction with its providers and other government departments. It should evaluate the impact of the temporary measures put in …
Gov response: The Government is grateful for the committee’s report and we remain committed to supporting those in our accommodation and those detained in our care, appropriately throughout this changing period. However, we do not believe that …
Position Not Stated
#48 —
Recommendation: We urge the Home Office urgently to review the way Mears has been operating during the pandemic, to consider its poor management of service users’ welfare, and the wider public health consequences of its approach.
Gov response: 18 Home Office preparedness for COVID-19 (coronavirus): institutional accommodation: The Government expects the highest standards from all of our contractors and we work closely with asylum accommodation providers to monitor and ensure they continue to …
Position Not Stated
#8 —
Recommendation: Similarly, procuring and distributing PPE involved a range of bodies, including the Department, Public Health England, local NHS providers and care homes, yet until the appointment of Lord Deighton in mid-April no one took the lead in making sure there …
Gov response: 1.1 The government agrees with the Committee’s recommendation. Recommendation Implemented 1.2 Information on the department’s COVID-19 Battle Plan, including the then senior responsible officers, was shared with the Comptroller and Auditor General on 5 June …
Accepted
#5 —
Recommendation: Staff in health and social care cannot be expected to be ready to cope with future peaks and also deal with the enormous backlogs that have built up unless they are managed well. We are deeply concerned about the frontline …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Recommendation Implemented 5.2 The department has published wellbeing guidance for all those working in adult social care, providing key advice and resources on maintaining mental wellbeing and …
Accepted
#44 —
Recommendation: It is not clear exactly which Government department or agency is ultimately responsible for coordinating border policy. Evidence from the Home Secretary suggested important roles for the Department of Health and Social Care, Public Health England and the Department for …
Gov response: The regulations were first signed by the Secretary of State for Health and Social Care are part of a coherent effort across the whole of the UK to tackle COVID-19 and protect the lives and …
Position Not Stated
#1 —
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Ministry of Justice and HM Prison & Probation Service on improving the prison estate.1
Gov response: 1. NHS resilience and recovery – Lee McDonough, DHSC; Ruth May, Chief Nursing Office for England 2. Social care resilience including workforce and minimising transmission – Michelle Dyson, DHSC 3. Supply and distribution of key …
Under Consideration
#19 —
Recommendation: The Committee notes the strong progress the PHSO has made in delivering against this objective and informing discussions in the international Ombudsman community. The Committee looks forward to hearing of further progress in this area.
Gov response: PHSO has commissioned a peer review to be carried out this year. As the panel is independent, the Chair–once appointed - will appoint the remaining members of the panel. The peer review will consider PHSO’s …
Response Not Attributed
HSSIB safety recommendations(244)— 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
Electronic patient record systems – electronic referrals for ongoing care
Oversight of pathways of care is undertaken and assurance is sought at a regional level.
Investigation Scope
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
CQC inspection actions(810)— showing 50 strongest matches
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
The Tunbridge Wells Hospital at Pembury
The service must ensure there are effective governance systems and processes to identify and manage incidents, risks, issues and performance and to monitor progress through completion of audits, action plans and oversight of improvements and reduce the recurrence of incidents …
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure systems and processes for maternity triage are reviewed to deliver a safe service in line with national guidance.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure that staff have carried out daily safety checks of emergency and specialist equipment.
Must Do
The Queen Elizabeth Hospital
The service should ensure emergency equipment is checked daily in line with their procedures.
Should Do
The Princess Royal Hospital
The trust should ensure to continue to use the audit data to drive improvements for patient care and treatment.
Should Do
The Princess Royal Hospital
The trust should ensure the governance system in place is effectively supporting all aspects of safe, quality care.
Should Do
The Princess Royal Hospital
The trust should ensure that they audit patient discharges undertaken under the fast track system.
Should Do
The Princess Royal Hospital
The trust should ensure that they complete audits to monitor effectiveness and care for children on neonates.
Should Do
The Princess Royal Hospital
The service should consider how it introduces a system to monitor 30-day mortality rates for patients delayed for over 5 hours in emergency department.
Should Do
The Princess Royal Hospital
The trust should ensure the store cupboard for clean equipment is moved from the dirty utility room into the discharge lounge.
Should Do
The Princess Royal Hospital
The trust should consider reviewing the governance structure throughout the organisation in order to ensure that only relevant information is presented to trust board.
Should Do
The Princess Royal Hospital
The trust should ensure systems to identify where action should be taken, through internal audit, are robust.
Should Do
The Princess Royal Hospital
The service must operate effective governance systems to ensure compliance with all relevant sections, such as but not limited to the risk register.
Must Do
The Princess Royal Hospital
The trust must ensure there is clear oversight of all patients in waiting areas.
Must Do
The Princess Royal Hospital
The trust must ensure there is a timely review of all open risks dated from 2009 to 2019.
Must Do
The County Hospital
The provider must ensure there are systems and processes to assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activities. It must assess, monitor and mitigate the risks relating to …
Must Do
Stroud Maternity Hospital
The service should consider the need for a separate risk register for Stroud Maternity Unit.
Should Do
Stroud Maternity Hospital
The service must ensure they have regular audit to demonstrate compliance with standards and procedures, to identify gaps, implement and monitor improvement Regulation 17(1)(2)(a)(b).
Must Do
Stroud Maternity Hospital
The service must ensure staff complete daily checks of emergency equipment. Regulation 12(1)(2)(a)(d).
Must Do
St Richard's Hospital
The trust must ensure that workforce data for the trust can be separated to show individual site performance.
Must Do
St Richard's 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
St Richard's Hospital
The service must review its existing IPC audit monitoring systems to identify any shortfalls in infection prevention and control and so action can be taken to make improvements when needed.
Must Do
St Richard's Hospital
The trust must ensure that the systems used to monitor WHO checklist compliance, including brief and debrief, are effective in demonstrating compliance and able to show areas for improvement effectively in line with NPSA guidance.
Must Do
St Richard's Hospital
The trust must ensure the monitoring of anaesthetic machine checks is recorded and aligns with best practice guidance.
Must Do
St Richard's Hospital
The trust must ensure that controlled drug records and the oversight of these are in line with national guidance.
Must Do
St Richard's Hospital
The trust must ensure that all staff receive timely appraisals in line with provider policy.
Must Do
St Richard's Hospital
The trust must ensure that staff complete mandatory training in line with their role and that oversight of targets is effectively monitored.
Must Do
Royal Victoria Infirmary
The service should ensure regular completion of the clinical assurance tool and clear action plans are available for all staff.
Should Do
Royal Victoria Infirmary
The service should ensure that clinical sharps waste bins are dated and labelled in accordance with national guidance.
Should Do
Royal Victoria Infirmary
The service should ensure that all equipment that requires removal from ward areas is stored securely.
Should Do
Royal Victoria Infirmary
The service should ensure that all clinical waste and sharps bins are marked and stored properly.
Should Do
Royal Victoria Infirmary
The service should ensure regular completion of the clinical assurance tool and clear action plans are available for all staff.
Should 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 …
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(6)
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1c
Urgent prioritisation of the national Beacon dashboard, with routine use embedded to support whole system learning and improvement, and regular public reporting. A real-time safety signals dashboard, overseen by a clinically and academically informed subgroup of the national oversight group to enable early identification of risk and timely intervention.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1b
A National Strategic Oversight Board should include all relevant national stakeholders with responsibility for perinatal services, the national perinatal team, and a service user representative, with the aim of providing comprehensive oversight and shared accountability. The Board should meet regularly to provide a single, coordinated mechanism for monitoring and acting …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1a
The appointment of national Clinical Directors or leads in obstetrics, neonatology, neonatal nursing and obstetric anaesthetics. These roles should form a National Perinatal Team, working alongside the Chief Midwifery Officer to advise the Welsh Government, drive policy development and implementation, and provide strengthened clinical oversight and accountability of Health Boards …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1d
A comprehensive, accessible governance map, accompanied by a clear narrative explanation of roles, responsibilities, decision-making routes and escalation pathways, should be developed and published within six months of the publication of this report.
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bii
The assurance assessment panel has benefited significantly from advice and challenge provided by a wider stakeholder group. We recommend this group is formally retained, meeting quarterly with clear terms of reference to inform the national strategic oversight Board, and that its membership is expanded to include educators, researchers and student …
wales
Accepted
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 1bi
We recommend that the planned National Maternity and Neonatal Voices Panel also includes representatives from community advocacy organisations representing populations at increased risk of poorer experiences and outcomes in perinatal services, and that it elects a representative to sit on the national strategic oversight Board.
wales
Accepted
Scottish Fatal Accident Inquiries(94)
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 …
Nov 2015
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
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
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
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
Muireann Caitlin McLaughlin
[61] I recommend that in the formulation of appropriate regulations consideration be given to banning the use of looped blind cords at all but not so as to create other, different hazards or to render blinds effectively inoperative. Safety warnings permanently attached to cords along with conspicuous warnings for the purchaser / supplier / fitter; [65] I recommend that BERR, …
May 2009
James Robert Hutchinson
I therefore recommend that drivers should be provided with a head torch if it is not reasonably practicable to provide fixed lighting.
Jul 2009
Thomas Andrew Tant
The analysis of security issues at page 75 of said report is however, in my view valuable in general terms as pointing to the need for secure lockable storage facilities in cells insofar as any penal establishment may lack such facilities.
Dec 2009
Kevin Alexander Davidson
It may be that at the end of the day too much responsibility rests with the driver in terms of determining the safety and security of any particular load and it may be that some consideration should be given to a system in which the driver and at least one other person is directed to always carry out a final …
Jan 2010
Ben Harry Robert McCreath
To protect against this , openings in a protective barrier should prevent the passage of a 100mm diameter sphere “ I recommend that the 100 mm rule should be applied to all non-domestic buildings and not only such buildings where the presence of children is anticipated. That should be the default setting and designers/architects/developers and their agents would require to …
May 2010
Christina Fraser
(a) All heavy goods drivers should be required to undergo compulsory training in loading techniques before being allowed to transport loads, which training should also be on a periodic basis. (b) No load should be transported unless its weight has been accurately ascertained. (c) Every employer involved in the transporting of loads should be required to keep a register of …
Jun 2010
Kevin Mykoliw
I recommend that operators should be reminded to comply with their operator’s licence and that positive steps should be taken swiftly to enforce such compliance. I recommend that operators be reminded when carrying out brake tests on public roads to carefully assess the proposed locus prior to commencing their tests. I also recommend that operators should be warned of the …
Aug 2010
David Clark
I trust that lessons have been learned and that there is now in place a more robust system of noting in clinical records and some form of audit to make sure that the noting is up to standard. To the layman it would seem that all services across Scotland should be operating to the same standard and that standard should …
May 2007
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
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