Significant event log failures
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
38 inquiry recs
9 PFD reports
1 committee rec
67 CQC actions
19 IMB recs
2 Scottish FAIs
10 Article 2 learning points
1 detention investigation rec
6 DHR recs
8 PHSO decisions
8 LGO/SPSO decisions
6 CQC enforcement actions
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(38)
6 — Encourage drivers to report faults
Recommendation: Drivers should be encouraged to report all actual or suspected faults, whether through formal fault reporting procedures or through CIRAS (paras 14.26, 16.4).
Unknown
45 — Senior officer checks information reaching wing
Recommendation: The senior officer on a wing should ensure that information arriving on the wing about a prisoner is recorded in the wing observation book. Particularly important information should be in red. When coming on duty, staff should read any entries …
Unknown
R12 — Single written channel for serious incident reports
Recommendation: We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved (para 5.14.12)
Gov response: Recommendation 12. We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved. We will shortly …
Accepted
R11 — Incident report on monitoring alarm failure
Recommendation: We recommend that in the event of failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again (para 5.11.6).
Gov response: Recommendation 11. We recommend that in the event of a failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again. This recommendation …
Response Unclear
R16 — Missed care incident reporting
Recommendation: If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
No response yet
F99 — National Patient Safety Agency functions
Recommendation: The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.
Gov response: Accepted in principle. This recommendation refers to the reporting of patient safety incidents by individuals as opposed to via the ‘standard’ route of uploading incident reports from organisations’ local risk management systems. It is predicated …
Accepted in part
F98 — National Patient Safety Agency functions
Recommendation: Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.
Gov response: Accepted in principle. Reporting of patient safety incidents involving severe harm and death is already mandatory nationally under the Care Quality Commission regulations and these incidents are actively reviewed by NHS England as well as …
Accepted in part
COVID-M1.6 — Triennial Pandemic Exercises
Recommendation: The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak …
Gov response: The government agrees that regularly programmed exercises should test pandemic preparedness. A ministerial, national level (Tier 1) exercise has been programmed for 2025 to test the response to a major pandemic. In addition, smaller scale …
Accepted
COVID-M1.4 — UK-wide Civil Emergency Strategy
Recommendation: The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. As a minimum, the strategy should: be adaptable; include …
Gov response: The government agrees with the Inquiry’s insights, and they align with our own reflections. The government is therefore implementing a common strategic approach to preparing for and responding to whole-system civil emergencies, which will form …
Accepted in part
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: DBT sees clear advantages of the recommendation but recognises that options to improve future delivery of redress will need to be carefully considered and the feasibility of an independent body will need to be properly …
Noted
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: DBT rejects this recommendation as we believe it comes into conflict with the principle of “full and fair” redress set out as we accepted Recommendation 2. DBT’s view is that it would not be fair …
Not accepted
MAI-152 — Recording equipment for incident commanders
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that all those who may be required to take up a command position in the event of a Major Incident are …
Gov response: Accepted in full
Accepted
MAI-84 — Review NWFC incident log information storage
Recommendation: North West Fire Control should review the way it captures and records key information on its incident logs in order to ensure that the information is stored in one place and is readily accessible at all times by those who …
Gov response: Accepted in full
Accepted
MAI-81 — Improve NWFC Major Incident record-making
Recommendation: North West Fire Control should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: Accepted in full
Accepted
MAI-71 — Improve NWAS Major Incident record-making
Recommendation: North West Ambulance Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: Accepted in full
Accepted
MAI-38 — Improve GMP Major Incident record-making
Recommendation: Greater Manchester Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: Accepted in full
Accepted
MAI-33 — Improve GMFRS Major Incident record-making
Recommendation: Greater Manchester Fire and Rescue Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: Accepted in full
Accepted
MAI-19 — Provide recording equipment to control room personnel
Recommendation: Consideration should also be given by those organisations to the provision of such equipment to key personnel within control rooms.
Gov response: Accepted in full
Accepted
MAI-14 — Improve BTP Major Incident record-making
Recommendation: British Transport Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: Accepted in full
Accepted
F100 — National Patient Safety Agency functions
Recommendation: Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.
Gov response: Accepted in principle. All serious incidents involving severe harm and death reported by individuals to via the on-line e-form, or any route, are routinely shared with the Care Quality Commission on a weekly basis. The …
Accepted in part
12 — Review incident investigation structures
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
17 — Keep accurate contemporaneous records
Recommendation: We remind shipowners and operators of the importance of the keeping of accurate contemporaneous records and of the importance of ensuring that their standing orders include instructions to that effect and that such instructions should be monitored closely.
Unknown
IHRD-31 — SAI Reporting Understanding
Recommendation: Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-17 — Recording Changes in Accountability
Recommendation: Any change in clinical accountability should be recorded in the notes.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Gov response: Accepted. A fundamental principle of the current complaints arrangements for handling NHS and adult social care complaints is that a case should be handled according to the needs of that individual case. Investigation should be …
Accepted
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.
Gov response: Accepted. Information on serious untoward incidents is shared routinely with the Care Quality Commission, and Quality Surveillance Groups have been established to support the sharing of information and intelligence more generally at a local level. …
Accepted
25 — Duty to report external investigation findings
Recommendation: We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external …
Gov response: 43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, …
Accepted
23 — Clear standards for incident reporting in maternity
Recommendation: Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there …
Gov response: 23. We accept this recommendation in principle. A new national, Independent Patient Safety Investigation Service will supplement existing practice. 24. The Investigation found that there were a substantial number of missed opportunities to uncover and …
Accepted in part
CLAR-3 — Remind agencies to keep detailed, accurate records, especially mortuary documentation
Recommendation: We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.
Unknown
IHRD-70 — Board Meeting Minutes Preservation
Recommendation: Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-48 — Mortality Meeting Recording and Audit
Recommendation: The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-45 — Post-Mortem Documentation Checklist
Recommendation: Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-32 — SAI Reporting as Disciplinary Offence
Recommendation: Failure to report an SAI should be a disciplinary offence.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
11 — Raise awareness of incident reporting and duty of candour
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
IHRD-29 — Record Keeping Audit
Recommendation: Record keeping should be subject to rigorous, routine and regular audit.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-24 — Blood Test Result Documentation
Recommendation: All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
SHI-4 — Standard form for derogations from guidance
Recommendation: The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in …
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
Prevention of Future Deaths reports(9)
Elsie May Treece
Concerns: The coroner noted an alleged incident where a patient fell was not recorded, raising concerns that staff may not be adequately reporting all inappropriate incidents, even when major harm is not immediately apparent.
Response (Burton Hospitals NHS): • The Trust stated that staff receive training on incident reporting, including procedures for using paper-based forms during system downtime. • The Trust confirmed that additional training and support for … (AI summary)
Responded
Thomas Burchell
Concerns: The coroner noted inadequate and incomplete medical and nursing record keeping, specifically regarding seizure charts. The report also highlights a need for more robust recording of events when patients develop seizures.
Response (The Borchardt Medical centre): • The Practice implemented a policy change requiring staff to add a code to computerised records on the day of arrival, to ensure clinicians are aware of and can access … (AI summary)
Overdue
Matthew Gunn
Concerns: An observed or reported epileptic event involving a Morrison's employee at work was not recorded by the employer.
Response (Morrisons): • A bulletin will be issued to all stores, instructing employees to contact a first aider for any observed epileptic event or temporary absence. • First aid training and policy … (AI summary)
Overdue
Janet Hall
Concerns: Concerns were raised about the Emergency Department's system for discharge letters, which relies on junior doctors manually transcribing blood results, leading to an incorrect statement about normal bloods. This process also limits GPs' ability to perform trend analysis.
Overdue
Julie Morrey
Concerns: The coroner noted a lack of communication between hospital departments regarding patient responsibility, leading to the patient being without fluids for over 24 hours. Additionally, there was no senior clinician review for 24 hours and a lack of policy for nursing staff to proactively manage her condition.
Response (University Hospitals of North Midlands NHS Trust): • A "Renal pathway for patients referred for admission from ED/AMU" has been agreed, and Trust Internal Professional Standards have been amended. • Emergency Department procedures now include escalation and … (AI summary)
Responded
Eileen Pollard
Concerns: The document used for daily call bell checks is pre-populated with 'P' for pass, which risks rooms being missed or failures not being accurately recorded, potentially affecting patient safety.
Overdue
Vivien Brunning
Concerns: Venous thromboembolism reviews were not undertaken at 24 and 72 hours post-admission, and prescribed daily heparin injections were omitted. An omission of medication was noticed but not reported through the Trust's incident reporting system.
Response (Croft Shifa Health Centre): • A practice meeting was conducted with GPs and administration staff to discuss patient documentation workflow. • Changes were agreed to the records management policy, requiring all DNA and Bardoc … (AI summary)
Overdue
Chloe Every
Concerns: Lack of contemporary medical notes, infrequent clinical observations, and a procedure performed without informed consent on an unconscious patient. The report also notes delays in incident reporting and coroner notification, which impacted the investigation.
Response (Barking Havering and Redbridge NHS Foundation Trust): • The Trust provides mandatory training for all staff on learning disability care, including Oliver McGowan training, and is recruiting more nurses with Learning Disability qualifications. • The Trust is … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care reported that Barking, Havering & Redbridge NHS Foundation Trust (BHRUT) has implemented daily checks by its Learning Disability Team, introduced specific care … (AI summary)
Responded
Richard Moss
Concerns: Referral documents completed by medical practitioners at the practice only generate an alert to colleagues if manually selected, rather than automatically upon completion of the document.
Response (Townhead Surgery): • The surgery held a significant event meeting to review its referral process. • It implemented an internal reporting system to identify unsent Rapid Access Chest Pain Referrals, which is … (AI summary)
Response (Townhead Surgery Update): • The surgery raised the IT issue with its Integrated Care Board. • The Integrated Care Board confirmed changes to the chest pain referral pathway for all local GPs. • … (AI summary)
Responded
CQC inspection actions(67)— showing 50 strongest matches
The Peter Gidney Neurodisability Centre
The home was not notifying CQC or the funding authorities of significant events.
Must Do
Meadow Green
The provider must ensure that notifications of other incidents are made to CQC in line with Regulation 18 (2) (e).
Must Do
The Lodge Care Home
Notifications of other incidents
Must Do
Ashbourne House - Torquay
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.
Must 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 must ensure all staff report incidents via the trust reporting systems.
Must Do
West Cumberland Hospital
The trust must ensure that systems and processes are in place to accurately review and categorise patient safety incidents logged by frontline staff.Regulation17(2)(a)(b).
Must Do
The York Hospital
The trust must ensure that all incidents are reported through the trust incident reporting system.
Must Do
The York Hospital
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively …
Must Do
Sunderland Royal Hospital
The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively …
Must Do
Sunderland Royal Hospital
The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively …
Must Do
South Tyneside District Hospital
The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within inappropriate timescales. The system must ensure incidents are effectively …
Must Do
Scarborough Hospital
The trust must ensure that all incidents are reported through the trust incident reporting system.
Must Do
Scarborough Hospital
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively …
Must Do
Royal Hallamshire Hospital
The trust must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Royal Hallamshire Hospital
The trust must ensure incidents including serious incidents are investigated within an appropriate timescale and improvements are made without delay.
Must Do
Royal Hallamshire Hospital
The trust must ensure incidents including serious incidents are identified, reported consistently, and categorised appropriately to reflect harm sustained by service users.
Must Do
Queen Elizabeth The Queen Mother 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
Queen Elizabeth The Queen Mother Hospital
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust should ensure all staff have regard to trust policy when reporting incidents and near misses.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all staff report incidents via the trust reporting systems.
Must Do
Northern General Hospital
The trust must ensure incidents including serious incidents are identified, reported consistently, and categorised appropriately to reflect harm sustained by service users.
Must Do
Mount Vernon Cancer Centre
The trust should ensure all incidents are reported on the trust electronic reporting system.
Should Do
Liverpool Walk in Centre
Review the significant event reporting system to ensure staff receive feedback when an incident has been reported.
Should Do
Leicester Royal Infirmary
The trust must ensure staff report all incidents in line with the incident reporting policy.
Must Do
Leicester General Hospital
The trust must ensure staff report all incidents in line with the incident reporting policy.
Must Do
King George Hospital
The service must ensure that the administration of rapid tranquilisation is recorded as an incident in line with national guidance.
Must Do
Hemel Hempstead General Hospital
The trust should ensure that all incidents are reported appropriately.
Should Do
Doncaster Royal Infirmary
The trust must ensure that all staff understand the trusts incident reporting system and that incidents are reported consistently and appropriately.
Must Do
Cumberland Infirmary
The trust must ensure that systems and processes are in place to accurately review and categorise patient safety incidents logged by frontline staff. Regulation 17(1)(2)(a)(b)(e).
Must Do
St Benedict's Hospice
The service must monitor the reporting of staffing related incidents in an objective and reliable manner; and should consider implementing more robust (NICE ‘red flag’) recording and monitoring procedures that do not rely on individual reporting by staff.
Must Do
Conquest Hospital
The trust SHOULD make sure all incidents are reviewed within 72 hours.
Should Do
Moorcroft Medical Centre
Evaluate the changes made to the significant event root cause analysis tool.
Should Do
Harrogate District Hospital
The service should complete all relevant documentation when incidents are reviewed.
Should Do
Dorset County Hospital
Theserviceshouldensureincidentsareharm-gradedandratedappropriately.
Should Do
Clifton Hospital
The trust should ensure staff complete an incident form when safeguarding referrals are made, in line with trust policy.
Should Do
Clacton Maternity Unit
The services should ensure its specifies which location incidents occur at when submitting trustwide National Reporting Live System (NRLS) incident reporting, to make it clear to regulators at which site incidents occur.
Should Do
TerraBlu Homecare
Registered persons had failed to notify CQC in a timely manner about incidents that had occurred.
Must Do
Ability Associates Limited - 77 The Street
The registered manager had not ensured they notified the Care Quality Commission of allegations of abuse and incidents reported to the police.
Must Do
Fairglen Residential Home
The provider must inform CQC of notifiable events.
Must Do
Dr French Memorial Home Limited
Notifications of other incidents
Must Do
Benedict House Nursing Home
The provider must ensure that the Care Quality Commission is notified of any allegation of abuse in relation to a person using the service.
Must Do
Sunderland Royal Hospital
The trust must implement an effective system to identify, report and learn from incidents involving the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure medical staff complete exception reports to identify trends and themes and use these to improve services for patients and staff.
Must Do
Northern General Hospital
The trust must ensure that serious incidents are reported and investigated in a timely manner in line with national guidance.
Must Do
Abbey Meads Surgery
Continue to audit and review historically missed alerts.
Should Do
St Benedict's Hospice
The service MUST ensure staff recognise the use of mechanical or pharmacological as restraint and ensure this is incident reported.
Must Do
Universal Care - Beaconsfield
The provider failed to ensure it notified us of events it was legally responsible to inform us.
Must Do
Universal Care - Beaconsfield
The provider failed to ensure they notified us when changes occurred.
Must Do
IMB individual recommendations(19)
London STHF (2024)
The Board stopped receiving Safer Detention Reports in July 2023 and despite many requests, these have not been forthcoming. This means that we do not have access to the data to enable us to monitor Suicide and Self Harm Warning Forms, Vulnerable Adult Warning Forms and Use of Force. After repeated requests at every Board meeting, we were eventually told …
Other
Swansea (2022)
Informing the Board about Care & Separation Unit (CSU) admissions and Good Order or Discipline (GOOD) reviews in line with the Memorandum of Understanding has been inconsistent (see paragraph 5.2.6). The Board acknowledges its absence from the prison for much of the reporting year but the requirement continued during remote monitoring and its previous report also highlighted this issue.
Governor / Director
Swaleside (2022)
The IMB is concerned at the occasional failure to be invited to serious incidents and planned moves to the CSRU and would appreciate the necessity for this to be reiterated to all senior staff.
Governor / Director
Exeter (2020)
Will the Governor continue to build on improvements to notify the Board of serious and other notifiable incidents or events?
Governor / Director
Accepted
Risley (2021)
There have been instances where the Board has not been called to serious incidents, particularly out of hours. What are your plans, going forward, to ensure that Board members may monitor and observe serious incidents, while maintaining all appropriate safety and security protocols?
Governor / Director
Thameside (2022)
More rigorous monitoring and analysis of cell bell data, especially data covering night-time calls, and address the system’s unreliability (see section 5.1).
Governor / Director
Wandsworth (2024)
In the past year, the IMB was not always informed of major incidents, particularly Deaths in Custody. Can you assure us that you will put a process in place to rectify this?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2024)
The Board recommends the examination and review of the low number of Rule 32/35 risk to health and risk of suicide cases, in order to check that the low number of cases is not indicative of the process failing to be used as it should be to identify those facing a deterioration of their health in detention and those at …
Home Office
Wayland (2021)
As our monitoring has revealed a significant likelihood that cell clearance certification procedures have not always been duly followed, the Board believes that the importance of managing an accurate and timely cell clearance certificate needs reinforcement on a national basis (see section 5.8).
HMPPS
In Progress
Thameside (2023)
Continue to scrutinise cell bell data to improve answering times. Consider strategies to deter prisoners who repeatedly mis-use the cell bell system.
Governor / Director
Implemented
Liverpool (2023)
The Board has raised several concerns about monitoring and oversight of UoF incidents. What further action will be taken to improve this area?
Governor / Director
Liverpool (2023)
The Board is not notified of all applicable incidents/events in line with the Memorandum of Understanding. In addition, the Board does not always receive the data or meeting invites as it should. What action will be taken to improve this area so the Board can monitor effectively?
Governor / Director
Isis (2023)
Can the Governor ensure that processes for making sure that cell bells are answered in the specified times are followed and monitored?
Governor / Director
Grendon (2020)
improvements in cell bell analysis and/or response times (see paragraph 4.3.7)
Governor / Director
In Progress
Swinfen Hall (2023)
What action will be taken to reduce the backlog of OASys reports that impacts negatively on outcomes for prisoners?
Governor / Director
Low Newton (2023)
How can the Board work with the prison to have better oversight of adjudications, as well as GOOD reviews held in the safety and support unit?
Governor / Director
Isle of Wight (2023)
When will the Governor put in place an effective means to monitor the impact of the literacy strategy?
Governor / Director
Isis (2023)
Can the Governor ensure that data regarding separate and restricted regimes is collated and analysed to provide a better understanding of these regimes’ use and impact?
Governor / Director
North East Midlands, Yorkshire & Humber STHF (2023)
We recommend that Border Force staff at STHFs ensure that all ongoing care and welfare checks are fully and properly recorded on the annex A form in the port.
Home Office
Health investigations(19)
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 18
Untoward incidents at Alexandra Road should be recorded in a separate log and an untoward incident policy should be introduced.
london
Independent Investigation into the care and treatment of X: October … — Rec 8
The Trust should review the systems in place to sign off action plans from serious incidents, and ensure that there is an assurance process to evidence implementation and embedded practice changes.
South Essex University Partnership NHS Foundation Trust
east_of_england
An independent external quality assurance review (published November 2019) can … — Rec 5:
The Trust should develop a programme of increased awareness of the need to accurately report incidents with the MHSOP wards and assure itself that incidents are being accurately reported.
north_east_yorkshire
An independent external quality assurance review (published November 2019) can … — Rec 5:
The Trust should develop a programme of increased awareness of the need to accurately report incidents with the MHSOP wards and assure itself that incidents are being accurately reported.
north_east_yorkshire
Independent investigation report into the care and treatment of Mr … — Rec 1
The Trust must ensure that staff complete incident forms at the earliest opportunity and that staff are clear about when this is.
midlands
An independent investigation into the care and treatment of mental … — Rec 5
The Trust should develop a programme of increased awareness of the need to accurately report incidents with the MHSOP wards, and assure itself that incidents are being accurately reported.
Tees Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Accepted
Independent investigation: Matthew Carter, Tooting (2006) — Rec R15
The trust should review its processes and procedures for alerting senior managers to serious incidents which have significant potential for undermining staff morale and whether they offer adequate support for staff and adequately explain the trust’s response to such incidents.
london
Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green — Rec R6
Haringey tPCT should ensure that there is a robust system in general practice for reporting all serious untoward incident and near misses including those related to mental health. The tPCT should include this in its audit programme to monitor the implementation of this recommendation.
london
*Independent investigation into the care of Mr A: March 2013 — Rec 10
A review should be conducted to ensure that the MHIRT is fully compliant with the incident reporting and investigation regime now operated by CPFT, including an assessment of the quality of the decision making processes leading to referral for internal investigation of adverse events.
Cambridge and Peterborough NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of a … — Rec 10
The Trust and their commissioners must be assured that the investigation, management and oversight of serious incidents and associated action plans is appropriately undertaken.
Greater Manchester Mental Health NHS Foundation Trust
north_west
Accepted
Independent investigation into the care and treatment of Mr S — Rec 4
The CCG should undertake an audit of Serious Incidents within the past 12 months with a view to confirming that action plans were monitored and tested.
Mr S, published on 16th December 2020. Mr S was in receipt of services from Central North West London NHS Trust
london
Accepted
Independent investigation into the care and treatment of Mr S — Rec 3
The CCG should assure itself within the next three months that it has robust systems and processes in place to monitor and test individual SI action plans. This should include finalising its SOP for the ‘internal management of Serious Incidents utilising “Datix”’
Mr S, published on 16th December 2020. Mr S was in receipt of services from Central North West London NHS Trust
london
Accepted
An independent review into the independent sector provider One to … — Rec 5
NHSE/I (and their successor body) should consider the guidance for commissioners regarding the overview, management, and assurance of incidents where there are complex care pathways with multiple providers, to ensure that there is clear accountability for oversight of all serious incidents. This should include reference to incidents where a service …
north_west
An independent review into the independent sector provider One to … — Rec 10
Commissioners should consider how they can be assured that they have oversight of low level incidents recorded by providers to allow the identification of trends and themes.
north_west
Independent investigation into the care and treatment of Mr DB: … — Rec 21
Pennine Care NHS Foundation Trust : change incident reporting and management policy to implement structures and processes as described in NHS Serious Incident Framework March 2015
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
External review of all Independent Investigations following Mental Health Homicides — Rec 7
It is recommended that the IIGC should develop additional metrics and key performance indicators to provide assurance of regional adherence to quality as well as process requirements of Independent Investigations and the Serious Incident Framework.
south_west
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 7c
A national perinatal incident repository to enable systematic learning from local and national reportable incidents.
wales
Accepted
Independent investigation into the care and treatment of Mr L — Rec 5
The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about: the type of records to be created and stored when conducting an internal investigation; storage and retrieval of clinical records, and reporting of misplaced clinical records, …
L This is the independent investigation report into the care and treatment of Mr L who committed a homicide in 2014. Mr L was in receipt of services from Oxleas NHS Foundation Trust
london
The Path to Safer Beginnings in Wales: National Assurance Assessment … — Rec 7b
A specialist sub-committee of the National Strategic Oversight Board should oversee Health Boards' delivery of the perinatal National Reportable Incident process, ensure timely, multidisciplinary and family-centred responses, and produce national thematic learning.
wales
Accepted
Scottish Fatal Accident Inquiries(2)
Brian French and Colin William Ferguson
Although it is outside the scope of Section 6(1) of the 1976 Act, I recommend that: Consideration should be given to the inclusion in the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995 (RIDDOR) of dangerous occurrences, where there is no actual injury but there is a high risk of serious injury or fatality.
Jun 2011
N
a. There should be greater communication and co-operation between NHST and NHS Grampian (“NHSG”) in relation to the care of patients who are resident in the geographical area of one authority and subject to treatment in a facility run by the other. b. NHSG should make greater efforts to co-operate in Significant Clinical Event Analysis (“SCEA”) inquiries in NHST where …
Jan 2018
Article 2 learning points(10)
— LP 7
NOMS may wish to consider whether the introduction and use of bespoke bound notebooks would be appropriate for use by personnel engaged in the management of serious or critical incidents. Similar documents are in use in other organisations for the purpose of recording, in one place, notes, thought processes and …
NOMS
Accepted
— LP W
A clearer policy should be developed about the nature and extent of investigations which should take place following incidents of self-harm, so that prisons know when a local investigation within the prison is likely to be adequate, when an internal Prison Service investigation by the Area Manager is needed and …
HMPPS
— LP 12
We recommend that clearer guidance is produced on what kind of immediate internal inquiry should be undertaken following acts of serious self-harm, what evidence should be collated and retained and what form of action planning should be set in place as a result.
HMPPS
Partially Accepted
— LP 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
HMP Whitemoor
Accepted
— LP 2
If they have not already done so, NOMS and HMP Whitemoor should consider if current procedures and staff training provide for the full and accurate completion of official prison documents. Adequate audit and storage arrangements should also be considered as part of any subsequent review. The investigation highlighted a high …
NOMS and HMP Whitemoor
Accepted
— LP 6
Archived records in accordance with PSO 9020 should be more clearly indexed to facilitate future investigations.
HMPPS
— LP V
When a case of near death occurs, the scene, documentation and any files should be secured in the same way as follows a death.
HMPPS
— LP U
In cases of near death or serious injury, the Governor should initiate an investigation as a matter of urgency, securing all relevant documents and evidence.
The Governor
— LP J
Managers must ensure that any downgrading in Cell Sharing Risk Assessment is documented correctly, giving valid reasons for any decision.
HMPPS
Accepted
— LP I
Cell moves in F Wing should be better documented and countersigned by management. If prisoners are moved for their safety and wellbeing, this should be noted in their prison files and ACCT document.
HMPPS
Rejected
Detention investigations(1)
PHSO casework decisions(8)
P-002443 — Hull University Teaching Hospitals NHS Trust
Ms F complained her daughter was admitted to ICU too late, the source of internal bleeding wasn't found or treated, and the death certificate listed an incorrect cause.
NHS in England
Feb 2024
P-004303 — King's College Hospital NHS Foundation Trust
Mrs F complained the Trust failed to perform a post-surgery CT scan and made an inappropriate discharge decision for her son, which she believes led to his death.
NHS in England
Upheld
Nov 2025
P-002460 — Surrey and Sussex Healthcare NHS Trust
Miss I complained her father did not receive appropriate care, lacked proper testing, suffered poor family communication, and faced inconsistent COVID-19 testing.
NHS in England
Partly Upheld
Feb 2024
P-002471 — King's College Hospital NHS Foundation Trust
Ms J complained the Trust used her left arm for an IV despite warnings about her cancer history and lymphedema risk, failed to log the incident, and allowed her catheter to overfill.
NHS in England
Feb 2024
P-002479 — Manchester University NHS Foundation Trust
Miss R complained about her father's care before his death, alleging a delayed procedure and that the family was not promptly informed about a cardiac arrest during treatment.
NHS in England
Feb 2024
P-002769 — Northern Care Alliance NHS Foundation Trust
Mrs E complained about an inadequate cancer surveillance plan and a delay in acting on scan results, causing a lost opportunity for earlier treatment and lack of reassurance about service improvements.
NHS in England
Partly Upheld
Jul 2024
P-004456 — Portsmouth Hospitals University NHS Trust
Ms N complained the Trust failed to identify, record, and treat complications during Mr L's LVP procedure, believing internal bleeding from the procedure caused his death.
NHS in England
Dec 2025
P-004487 — University Hospitals Sussex NHS Foundation Trust
Mr Y complained his mother was left unattended, leading to a fall and subsequent death. He also criticised the Trust's investigation for inconsistencies and downplaying the incident.
NHS in England
Dec 2025
LGO / SPSO decisions(8)
21-010-289 — Sheffield City Council
Summary: Miss H complains the Council and Trust significantly delayed her son J’s Education, Health and Care Plan annual review, and J did not receive the 1-1 speech and language therapy sessions in his plan. There was fault by the Council and Trust. There were long delays in the annual …
LGO (Local Government & …
Education
Upheld
Aug 2022
25-003-138 — Suffolk County Council
Summary: The Council was at fault. It did not issue Mrs X’s child, Y’s, decision letter or Education, Health and Care (EHC) Plan within the statutory timescales after Y’s late January 2025 annual review. It also communicated poorly with Mrs X. The symbolic payment the Council has already offered to …
LGO (Local Government & …
Education
Upheld
Dec 2025
25-001-155 — West Northamptonshire Council
Summary: Miss X complained the Council failed to adhere to the statutory timeframes for issuing her child, Z’s, Education, Health and Care Plan, and it failed to provide Z with access to suitable education. We find the Council at fault for a delay in issuing a final Education, Health and …
LGO (Local Government & …
Education
Upheld
Dec 2025
24-023-490 — Cheshire West & Chester Council
Summary: The Council is at fault for poor communication and delay in the annual review process, causing distress. It also failed to provide education. The Council has accepted it is at fault and provided a suitable remedy.
LGO (Local Government & …
Education
Upheld
Dec 2025
25-000-070 — Walsall Metropolitan Borough Council
Summary: I find fault and delay by the Council in securing special educational provision. Z has missed out on specialist therapy and other support for over two terms. This is an injustice. The Council has agreed to apologise, make a symbolic payment and service improvements. The complaint is upheld.
LGO (Local Government & …
Education
Upheld
Dec 2025
24-022-210 — Somerset Council
Summary: We have found the Council at fault for its delay in issuing a final amended Education, Health and Care Plan for Miss X’s son, Y ahead of his transfer to post-16 education. This resulted in Miss X and Y suffering avoidable distress. We have also found the Council at …
LGO (Local Government & …
Education
Upheld
Dec 2025
201709143 — Fife NHS Board
Mr C complained about the board's weight management service at Queen Margaret Hospital. In the course of our investigation, we took independent advice from a bariatric surgeon (a doctor who specialises in the causes, prevention and treatment of obesity). Mr C complained that the service refused to offer him bariatric …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2021
25-002-113 — Lancashire County Council
Summary: Mrs B complained the Council has failed to update her son’s Education, Health and Care (EHC) Plan since the first annual review and its communication with her has been poor. There was fault by the Council. It did not meet statutory timescales during the annual review process and issuing …
LGO (Local Government & …
Education
Upheld
Jan 2026
Domestic Homicide Reviews(6)
Leeds — recommendation 2
Safeguarding lead in Surgery 1 to review the significant event process to ensure all significant events are reviewed. This will include unexpected death or serious injury of a patient, or where wider learning and improvements to safeguarding practice can be obtained to ensure multi-disciplinary discussions of the learning identified in …
Surgery 1
Bedford — recommendation 3.21.
Agencies working with families or individuals where domestic violence is present or suspected are recommended to keep a chronology of significant events and up to date records to detect patterns, escalation, new risk indicators such as pregnancy, and rising levels of risk.
All Agencies
Rotherham — recommendation 5
The Yorkshire Ambulance Service should provide a written response to the potential learning identified in the DHR. This includes the recording of contact with patients and the capacity of responders recognising, following up and making referrals about domestic abuse.
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Wiltshire — recommendation R30
All Offender Managers should undertake an OASys review following a significant event to review the risk of serious harm
National Probation Service-Middle Managers-Gloucestershire and Wiltshire …
Wolverhampton — recommendation The Health Centre: 2
The notification of domestic violence must stimulate internal practice review, along the lines of a significant event analysis.
The Health Centre
East Sussex — recommendation SCCG3
Following significant events at the surgery, where risk to individuals has been identified, that a review is undertaken to ensure all relevant information is shared around identified risks.
Sussex Clinical Commissioning Groups
West Sussex Clinical Commissioning …
CQC enforcement actions(6)
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
The CQC inspected an acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital in May. Inspectors found that staff could not observe patients in all parts of the ward, recording of patient observations were …
Fulbourn Hospital, Cambridge
Jul 2022
Warning Notice: Blackpool Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Blackpool Teaching Hospitals NHS Foundation Trust following an inspection in September and October. The CQC required the trust to make significant improvements regarding assessing and managing risks to patients waiting …
Jan 2022
Warning Notice: Leeds Teaching Hospitals NHS Trust
Section 29A warning notice covering maternity and neonatal services at Leeds General Infirmary and St James's University Hospital, following unannounced inspections in December 2024 and January 2025. CQC identified breaches relating to learning from incidents, risk management, the safety of …
Leeds General Infirmary and St James's University…
Jun 2025
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
Warning notice served following an inspection of wards for older people with mental health problems on 28–29 January 2026. CQC found leaders had missed some concerning gaps in people’s safety. Two patients sustained unreported broken bones from unwitnessed injuries; safeguarding …
Fulbourn Hospital and the Cavell Centre
Mar 2026
Warning Notice: Essex Partnership University NHS Foundation Trust
Warning notice served following an unannounced inspection on 21 November 2025. CQC found leaders at 439 Ipswich Road weren’t always acting quickly on safety concerns raised by their staff or the people in their care. Safeguarding incidents affecting physical or …
439 Ipswich Road
Feb 2026
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC identified significant and serious safety concerns during the surgery inspection. These related to safe staffing, escalation when people were deteriorating, record keeping and learning from incidents. Due to these issues, the trust has been told to make significant improvements …
Bishop Auckland Hospital, Darlington Memorial Hos…
Nov 2025