Staff policy awareness
Absence of a system to confirm that all staff have read and understood existing, updated, or new policies, procedures, and guidance documents.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
IOPC learning recommendation
95match
Police response to an abandoned emergency call – Cleveland Police, March 2020
The IOPC recommends that Cleveland Police policy and guidance documents are relevant and up to date, ensuring standard roles and responsibility policy documents for all supervision and staff working within the control room are in place, fit for purpose and reviewed on a regular basis. If policies/processes change then Cleveland Police should ensure that guidance is updated as...
Matched on
terms: awarenes, policy, staff
Inquiry recommendation
86match
38 - Government department safeguarding policy reviews
The Cabinet Office must ensure that each government department reviews its child safeguarding policy or policies in light of the expert witness report of Professor Thoburn. There must also be published procedures to accompany their policies, in order that staff know how to enact their department's policy. All government departments must update their safeguarding policies and procedures regularly,...
Matched on
terms: policy, staff
PFD report
77match
Seweryn Glowinski
Serious communication breakdown between prison units, incorrect documentation due to "cutting and pasting" prisoner information, and senior staff unawareness of segregation policies for at-risk prisoners.
Matched on
terms: awarenes, staff
PFD report
77match
Mary Chapman
The hospital's discharge policy is unclear regarding staff responsibilities and communication for critical post-discharge investigations. There's a lack of evidence that new procedures or multidisciplinary approaches have improved patient safety or consistent practice.
Matched on
terms: policy, staff
Inquiry recommendation
77match
39 - Political party safeguarding policies
All political parties registered with the Electoral Commission in England and in Wales must ensure that they have a comprehensive safeguarding policy. All political parties must also ensure that they have procedures to accompany their policies, in order that politicians, prospective politicians, staff and volunteers know how to enact their party's policy, which must be published online. All...
Matched on
terms: policy, staff
IOPC learning recommendation
77match
Recommendations - West Midlands Police, June 2021
The IOPC recommends that West Midlands Police create a policy on handling concern for welfare calls. This policy should cover the responsibility for informing third parties and should provide guidance for officers and staff members dealing with an enquiry relating to anyone raising concern for the welfare of another person. This recommendation is made following a DSI investigation...
Matched on
terms: policy, staff
IOPC learning recommendation
76match
Recommendation - Hertfordshire Constabulary, April 2026
The IOPC recommends that Hertfordshire Constabulary take steps to assure itself that police officers and staff likely to be involved in the handling of cross-border missing person investigations, especially those where mental health and safeguarding risks are present, are aware of: - Significant local policy, guidance (including Concern for Welfare Policy), standard operating procedures (SOP) (including the Missing...
Matched on
terms: policy, staff
HSSIB recommendation
74match
Interim report: Retained swabs following invasive procedures
Organisations can improve patient safety by using consistent terminology in national and local guidance when describing the responsibility for the reconciliation of items used in surgery and invasive areas, including swabs. How is information about swabs communicated? Challenges in communication between operating theatre team members were frequently highlighted in the serious incident reports. For example, there were incidents...
Matched on
terms: awarenes, staff
PFD report
73match
Rosalind Flett
Ambiguity in the Trust's search policy created a gap between "advanced" and "intimate" searches, preventing staff from conducting thorough searches and potentially missing concealed items.
Matched on
terms: policy, staff
PFD report
73match
Michael Dent-Jones
National Probation Service Approved Premises staff and management were unaware of and not implementing policies for managing residents' prescribed medication. Procedures were absent, and staff had not read essential safety documents, indicating broader safety failures.
Matched on
terms: staff
PFD report
73match
Liridon Saliuka
There was a lack of clear, accessible documentation detailing a prisoner's disability adjustments and a general lack of disability awareness among prison staff, leading to inappropriate assumptions about his capabilities.
Matched on
terms: awarenes, staff
CQC action
73match
Royal Victoria Infirmary
The trust must ensure all staff are aware of and consistently follow the trust policy, systems and processes to safely prescribe, administer, record and store and dispose of medicines.
Matched on
terms: policy, staff
IOPC learning recommendation
73match
Recommendations - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police should take steps to formalise the escalation and vulnerability doctrines (as set out in the force document “HMIC Observations and action taken following September 2017 Inspection”) into a compulsory policy and take step to ensure all contact staff are aware of their responsibilities under the policy. If this is formalised into...
Matched on
terms: policy, staff
PFD report
69match
Theresa Robertson
The surgery failed to document critical patient calls and consultations. A doctor prescribed medication for a high-risk patient outside policy, with no audit to identify similar systemic breaches in prescription safety.
Matched on
terms: policy
PFD report
69match
Shirley Froggett
New Lodge Nursing Home lacked robust systems to ensure staff compliance with patient care plans, policies, and protocols.
Matched on
terms: staff
PFD report
69match
William Savory
There was a significant two-hour delay in initiating the missing persons protocol for an informal patient, as staff were unaware of the requirement to act immediately. This lack of awareness poses a risk of future delays and deaths.
Matched on
terms: awarenes, staff
PFD report
69match
Cariss Stone
Staff lacked clear understanding of patient observation policy, and ligature cutters were not routinely supplied in a ward with known self-harm risks, posing significant safety concerns.
Matched on
terms: policy, staff
PFD report
69match
Jada Monoja
An online risk assessment tool is not systematically updated or used per policy, resulting in incomplete and potentially misleading patient risk assessments, hindering effective management.
Matched on
terms: policy
HSSIB recommendation
69match
Residual drugs in intravenous cannulae and extension lines
Consumable IV equipment may be subject to change for a range of reasons which may include availability, cost, newer/better variants, and quality. Training and awareness of these changes is rarely provided, but there is a risk that staff are not made aware of changes to specification and/or device performance.
Matched on
terms: awarenes, staff
Scottish FAI
69match
Allan Menzies
However, the criteria to be used should, in my opinion, be known to both the staff and the prisoners and ought to include inter alia the index offence, the issues behind it, his home circumstances, his personal preferences within reason, any outstanding appeal and the length of time spent within the NIC, any health issues and with the...
Matched on
terms: staff
CQC action
68match
Montagu Hospital, Mexborough
Thetrustshouldcontinuetoensureallstaffcompletemandatorytraininginlinewithtrustpolicy.
Matched on
terms: policy, staff
Detention investigation recommendation
68match
Independent Investigation into Concerns about Brook House Immigration Removal Centre - Rec R47
The SMT should undertake a programme of awareness-raising among staff to improve their understanding and use of the anti-bullying policy. (To be completed within 3 months)
Matched on
terms: awarenes, policy, staff
CQC action
66match
The Newcastle Clinic
The service should have a system in place to confirm all staff have read existing, updated or new polices, procedure and guidance documents.
Matched on
terms: staff
IOPC learning recommendation
66match
Recommendations - South Wales Police, July 2022
The IOPC recommends the National Police Chiefs’ Council (NPCC) shares the learning from this IOPC investigation with force custody leads, asking them to take steps to ensure: Custody staff understand that the Prisoner Escort and Custody System (PECS) is a stand-alone system which does not interface with any other police systems. Therefore, any existing or new information recorded...
Matched on
terms: staff
PFD report
65match
Rajesh Parkash
Failures in staff communication regarding updates and driving guidance, insufficient ongoing driver training, and inadequate supervision requirements for paramedics pose systemic risks.
Matched on
terms: staff
PFD report
65match
Arthur Fry
A communication breakdown between the MRI department and the consultant's team led to a critical MRI scan being cancelled due to unknown consent requirements, potentially impacting patient care. Tighter controls are needed for procedure requisitions.
Matched on
terms: staff
PFD report
65match
Maureen Flynn
A critical falls risk assessment was not completed, and staff were unaware of this omission due to a lack of system to alert them. The patient safety investigation also failed to identify this issue.
Matched on
terms: staff
PFD report
65match
Wayne Cornlouer
An emergency coding system for medical emergencies was not initially in Night Orders, raising concerns if all staff are now aware of its recent inclusion and proper use.
Matched on
terms: staff
PFD report
65match
Henry Holcombe
The Trust's staff are consistently failing to comply with therapeutic engagement and observation policies, especially regarding night-time monitoring of patients.
Matched on
terms: staff
PFD report
65match
Cpl Ryan Lovatt
The alcohol policy for Op Cabrit is unrealistic and poorly understood, potentially promoting binge drinking, while the critical "shark watch" role for sober supervision lacks formalization and clear communication.
Matched on
terms: policy
CQC action
65match
William Harvey Hospital
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy.
Matched on
terms: policy, staff
Scottish FAI
65match
Mark Patrick Hutton
(1) The welfare of prisoners has to be the priority for custody staff. The other duties that are covered by those staff, such as preparing prisoners for release, dilutes their ability to focus on the priority that is the prisoners’ welfare. The Police Service of Scotland should review the staffing levels in the custody suite as well as...
Matched on
terms: staff
Committee recommendation
64match
#15 - Fourteenth Report: Readying the NHS and social care for the COVID-19 peak
The Department stressed that it had to respond quickly to the COVID-19 pandemic often with “imperfect knowledge”, which was why its approach had altered over time.43 But Care England told us that PPE guidance had changed no fewer than 40 times, causing confusion and anxiety to service providers and staff.44 When we asked why the PPE guidance had...
Matched on
terms: staff
CQC action
64match
Queen's Hospital
The service must ensure that staff follow policy to identify and document patients who are on time critical medicines.
Matched on
terms: policy, staff
CQC action
64match
Yeovil District Hospital
The service should ensure that all staff adhere to the uniform policy to maintain effective infection prevention control.
Matched on
terms: policy, staff
CQC action
64match
University Hospital North Durham
The service must ensure staff complete all environmental and emergency equipment safety checks in accordance with trust policy.
Matched on
terms: policy, staff
CQC action
64match
Darlington Memorial Hospital
The service must ensure staff complete all environmental and emergency equipment safety checks in accordance with trust policy.
Matched on
terms: policy, staff
CQC action
64match
Cambeck Close
We have made a recommendation to ensure all current medicines advice is available for staff and the medicines policy reflects practices at the service.
Matched on
terms: policy, staff
HMICFRS recommendation
64match
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • improve how it engages with its staff to gain their commitment to the service’s values and associated behaviours;...
Matched on
terms: staff
IOPC learning recommendation
64match
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) ensures that its call handlers are aware that they have discretion when assigning the length of time slots for police officers to attend car appointments for allegations of sexual offences. This follows an IOPC investigation where an Emergency Response Team (ERT) Officer attended a fast-food restaurant drive-through to conduct...
Matched on
terms: policy
Detention investigation recommendation
63match
Independent Investigation into Concerns about Brook House Immigration Removal Centre - Rec R49
The SMT with the violence reduction manager should undertake a development programme with staff to: • develop their confidence and skills in dealing with disruptive detainees; and • improve their awareness and understanding of the anti-disruption policy and how it should be implemented. (To be completed within 3 months)
Matched on
terms: awarenes, policy, staff
Committee recommendation
62match
#26 - Code of Practice for resident communication during remediation shows inconsistent practice and limited awareness
In 2023, MHCLG launched a Code of Practice to support improved communications during remediation. The HBF and the NHF told us that developers and social housing providers had agreed to follow the code. EOCS told us the code was “a long time coming” and had been heavily revised at the last minute. It told us that information on...
Matched on
terms: awarenes
PFD report
61match
Ryan Chapman
Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
Matched on
terms: staff
PFD report
61match
Doris Taylor
The coroner noted that staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such. The door-closers on all doors should be in a safe working condition.
Matched on
terms: staff
PFD report
61match
John Lowe
Nursing staff incorrectly believed 1:1 care could not be provided for falls risk alone, only for mental health needs, regardless of a patient's physical care requirements.
Matched on
terms: staff
PFD report
61match
Mark Groombridge
There was no direct communication between the local offender manager and the clinician responsible for the patient's care before the recall paperwork was issued, and there was confusion about the recall process among probation staff.
Matched on
terms: staff
PFD report
61match
Valmai West
Inadequate staffing levels in the Emergency Department led to staff not following hospital protocol or NICE guidance for patient observations, posing a risk to future patients due to insufficient monitoring.
Matched on
terms: staff
PFD report
61match
Khalid Abiaz
A prison officer failed to open an ACCT despite clear suicide risk information, showing a misunderstanding of mandatory policy. This indicates a failure in training regarding the revised ACCT procedures for prisoners at risk of self-harm.
Matched on
terms: policy
PFD report
61match
Ash Bannister
Critical safety failures included undocumented removal of ligature risk assessments, poor inter-home communication, and inconsistent "ad hoc" waking night cover lacking clear policy, leading to prolonged unsupervised periods.
Matched on
terms: policy
PFD report
61match
Susan Edwards
A critical lack of a hospital system meant prescribed mechanical thromboprophylaxis was not provided for 18 days, with no staff detecting the omission, posing a risk to patients requiring this treatment.
Matched on
terms: staff