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.
Source spread
Where this theme appears
This theme appears across 24 independent accountability sources, so the source mix matters as much as the headline total.
135 inquiry recs
68 PFD reports
146 committee recs
28 HSSIB recs
387 CQC actions
93 HMICFRS recs
1 ICIBI rec
23 PPO recs
48 IOPC recs
2 NAO recs
233 IMB recs
12 IMB reports
19 Scottish FAIs
3 Article 2 learning points
34 detention investigation recs
1404 DHR recs
2 PHSO decisions
224 LGO/SPSO decisions
2 ISC reports
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(135)— showing 50 strongest matches
16 — Drivers and staff to use formal fault reporting
Recommendation: Railtrack and TOCs must impress on drivers and other staff the need to use formal fault reporting procedures where the Rules so provide, and that the duty to report a fault must be performed personally and the report delivered to …
Unknown
15 — Emphasise compliance with the Rule Book
Recommendation: All parties must emphasise the need to comply with the Rule Book and must not condone departures (para 7.9).
Unknown
11 — Avoid using several documents for one operational issue
Recommendation: The use of more than one document (whether Rules, Group Standards or otherwise) to cover a single operational issue should be avoided, save where proper reasons exist for use of multiple sources (para 15.9).
Unknown
10 — Rules and Group Standards clear and unambiguous
Recommendation: Railtrack must ensure that Rules and Group Standards applicable to operators, including drivers, are clear and unambiguous. In particular, Railtrack should urgently complete the review of operating Rules to ensure they are workable in the privatised, fragmented industry (para 16.6).
Unknown
27 — Guidance on signals-on control
Recommendation: The signallers at Kings Cross PSB should be provided with guidance to ensure that they have a clear understanding of the circumstances in which the signals-on control is to be used.
Unknown
16 — Clarify RT/CE/S/053 inspection timing
Recommendation: Network Rail Company Standard RT/CE/S/053 should be revised to remove ambiguity about whether the inspection required by paragraph 12 is to be undertaken at the same time as a detailed inspection or as part of the three-monthly/six-monthly inspection required by …
Unknown
15 — Clarify RT/CE/S/103 inspections
Recommendation: Network Rail Company Standard RT/CE/S/103 should be revised to clarify the following: • Paragraph 4.4 as to how often track gauge in S&C is to be measured and by whom (ie basic inspector, supervisor or track engineer). • Paragraph 8.1.2 …
Unknown
12 — Common understanding of Rule Book clause 3.3
Recommendation: Signallers and technicians should have a common understanding of the types of work that are permissible under Clause 3.3 of Module T1A of the Rule Book GE/RT8000.
Unknown
1 — Review stretcher bar nut guidance
Recommendation: The effectiveness of the guidance contained in Network Rail Company Code of Practice RT/E/C/10179, The Set Up and Maintenance of Adjustable Stretcher Bars - A Good Practice Guide, in relation to the positioning and tightening of stretcher bar nuts, should …
Unknown
64 — Guidelines and disciplinary proceedings
Recommendation: Guidelines relating to the requirements of the Human Tissue Act 1961 and the obtaining of fully informed consent shall be drawn up and provision made for breach to result in disciplinary proceedings which could lead to suspension, dismissal or financial …
Unknown
57 — Instruct doctors on Human Tissue Act
Recommendation: The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Human Tissue Act 1961, on the basis of our analysis, and the need for strict …
Unknown
56 — Pathologists limit retention
Recommendation: The Royal College of Pathologists shall instruct all practising histopathologists that they shall not retain samples and organs beyond those reasonably incidental to establishing the cause of death unless there is also written consent properly obtained under the Human Tissue …
Unknown
47 — Coroners’ Society instructions
Recommendation: The Coroners’ Society shall instruct Coroners that: – in the proper exercise of their judicial discretion, the decision to order a post mortem examination is not to be delegated to Coroner’s Officers and Deputy Coroners must be available at all …
Unknown
44 — Do not raise Coroner unless reportable
Recommendation: Clinicians shall not mention to the next of kin the possibility of an examination under the Coroner’s jurisdiction unless the death is reportable to the Coroner.
Unknown
43 — Follow Chapter 10 on retention
Recommendation: Clinicians wishing to retain organs or samples after the end of the Coroner’s process for the purposes currently allowed under the Human Tissue Act 1961 shall follow the Recommendations in Chapter 10.
Unknown
41 — Instruct doctors on Coroner’s Act
Recommendation: The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Coroner’s Act 1988 and in particular the circumstances in which it is obligatory to report …
Unknown
8 — Inform staff of procedure in force
Recommendation: The Chief Executive and Trust Board shall inform all staff when a Serious Incident Procedure is in force.
Unknown
137 — Departures from guidelines not a breach
Recommendation: A departure from suggested guidelines should not be automatically seen as a breach of good practice (17.78).
Unknown
62 — Full written instructions for removal
Recommendation: At least in complex cases those involved in the removal of the child should be given full written instructions (16.35).
Unknown
38 — Guidance on instructing removal
Recommendation: Guidance should be given on the occasions on which the discretion to instruct removal should be exercised (16.7).
Unknown
27 — Guidelines as guidance, not mandatory rules
Recommendation: While guidelines should be available for practitioners working in cases of child sexual abuse they should not be mandatory rules but guidance for normal procedure (15.55-56).
Unknown
38 — Display of issued permits to work
Recommendation: Copies of all issued permits to work should be displayed at a convenient location and in a systematic arrangement such that process operating staff can readily see and check which equipment is under maintenance and not available for operation (para …
Unknown
13 — Awareness of emergency plan responsibilities
Recommendation: It is essential that those who would be required to take action under the Windscale emergency plan are fully aware of the responsibilities the plan places on them (para 11.30).
Unknown
5 — Consult crews and train on testing policy
Recommendation: Owners and operators should discuss all these questions with representatives of officers and crews before they are included in contracts and they should embark on an education and training programme for all employees in order to ensure that they understand …
Unknown
76 — Time to read mental disorder booklet
Recommendation: Profiled time should be set aside for staff to read the booklet explaining the main components of the mental health awareness training course. The booklet should include advice given on the course about how prisoners with particular disorders should be …
Unknown
55 — Wing officers calling for reviews
Recommendation: Wing officers should be reminded of the need to call for a review of an assessment when the necessity for one is triggered by some occurrence which might affect the prisoner’s emotional well-being.
Unknown
47 — Model procedure for external report comments
Recommendation: The Prison Service should publish a model procedure dealing with how establishments should bring Prison Service Orders and other instructions, whether national or local, which affect the management of prisoners to the attention of staff. The model procedure should be …
Unknown
12 — Guidelines on requests to share with named prisoner
Recommendation: The Prison Service should publish guidelines to assist officers in handling requests by prisoners to share a cell with a particular prisoner. Practical problems should not be treated as an insuperable hurdle preventing an otherwise suitable move of a prisoner …
Unknown
FP75 — Recommendation 75
Recommendation: COPFS should ensure that appropriate written guidance as to fingerprint evidence is available to its staff. COPFS should also ensure that a sufficient number of lawyers fully conversant with fingerprint evidence are available to deal with any issues that may …
No response yet
FP68 — Recommendation 68
Recommendation: Cases where there is scope for a difference of opinion should not be classified as ‘erroneous’. The cases that merit investigation are where there may have been a mistaken fingerprint analysis or a breach of accepted procedures.
No response yet
FP4 — Recommendation 4
Recommendation: Differences of opinion between examiners should not be referred to as disputes.
No response yet
51 — Review Catholic safeguarding policies manual
Recommendation: The Catholic Safeguarding Advisory Service should review its policies and procedures manual and the documents within it to ensure that they are consistent, easier to follow and more accessible.
No response yet
42 — Church in Wales provincial safeguarding officers
Recommendation: The Church in Wales should make clear that the operational advice of provincial safeguarding officers must be followed by all members of the clergy and other Church officers. It should be enshrined in policy that those who are volunteers and …
No response yet
39 — Political party safeguarding policies
Recommendation: All political parties registered with the Electoral Commission in England and 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 …
Gov response: The government agrees that political parties should have in place a comprehensive child safeguarding and whistleblowing policy alongside the appropriate procedures. However, the Electoral Commission – whose remit is focused on electoral law – has …
Accepted in part
38 — Government department safeguarding policy reviews
Recommendation: 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 …
Gov response: All government departments have been made aware of the Inquiry’s recommendation and of the contents of Professor Thoburn’s detailed report. As Professor Thoburn’s report acknowledges - ‘It is appropriate that safeguarding policies and procedures will …
Noted
36 — Guidance on DBS for overseas work
Recommendation: The Home Office should ensure explanatory guidance is issued, providing clarity to recruiting organisations and individuals concerning the use of the Disclosure and Barring Service scheme for work and volunteering outside the UK.
Gov response: 22. The DBS currently signposts applicants to the ICPC if their work abroad makes them ineligible for DBS certificates. The Home Office will work with the DBS to ensure that this message is reinforced in …
Accepted
30 — Amend Canon C30 on safeguarding due regard
Recommendation: The Church of England should amend the current canon requiring clerics to comply with the Bishop's Guidance on Safeguarding. The use of the words 'due regard' in Canon C30 is an acceptable term of art, but lacks sufficient clarity. Very …
Gov response: 2 Amendments and repeals (1) Section 5(1) to (2A) of the Safeguarding and Clergy Discipline Measure 2016 (duty to have due regard to House of Bishops’ guidance) is repealed. (2) In section 6(3) of that …
Accepted
F9 — Fundamental standards of behaviour
Recommendation: The NHS Constitution should include reference to all the relevant professional and managerial codes by which NHS staff are bound, including the Code of Conduct for NHS Managers.
Gov response: Accepted in principle. We support the principle of making clear which codes staff are expected to follow. However, as the NHS Constitution is intended to be a succinct and enduring document, the details of codes …
Accepted in part
F7 — Clarity of values and principles
Recommendation: All NHS staff should be required to enter into an express commitment to abide by the NHS values and the Constitution, both of which should be incorporated into the contracts of employment.
Gov response: Accepted in principle. It is important that employers are able to recruit and retain the caring and compassionate staff the NHS needs. NHS Employers will support NHS organisations in developing and strengthening local policies and …
Accepted in part
BAHA-19 — JDP 1-10 Redraft Clarity
Recommendation: In the current redrafting of JDP 1-10 and in future subordinate doctrine and instructions regarding CPERS: (1) plain English, simplicity of structure and brevity should be given greater priority while allowing for the target audience and complexity of the subject …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
BAHA-6 — Five Techniques Terminology
Recommendation: In the interests of clarity for all, the five techniques should be referred to as being banned or prohibited rather than proscribed.
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
POH-11 — Apply best offer principle equally in GLOS
Recommendation: The "best offer" principle which will apply in HSSA, as explained in response to Recommendation 10, shall be equally applicable in GLOS.
Gov response: The minister announced on 8 July that DBT would adopt a best offer principle at panel stage on the GLO, HSSA and HCRS schemes. DBT consulted the Advisory Board, Sir Ross Cranston and claimants’ legal …
Accepted
167 — Guidance for Reporters
Recommendation: Consideration should be given to the preparation of guidance for Reporters to secure greater uniformity across Scotland in their practice (18.56).
Unknown
2 — Avoid undefined labels in abuse cases
Recommendation: As regards terminology it is recommended that in the investigation and practical management of cases of child sexual abuse care should be taken to avoid the use of labels without a common understanding of the definition and the purpose of …
Unknown
21 — Ten-foot width guidance
Recommendation: Consideration should be given to the need for guidance to be included in training material, or in the Rule Book GE/RT8000, that specifies the width of ten-foot that is required to enable a person to stand in safety between two …
Unknown
19 — Revise basic visual inspection procedures
Recommendation: The planning, operating, and recording of basic visual inspection procedures, as prescribed in RT/CE/S/103, should be reviewed. Revised Track Inspection Sheets and Track Patrol procedure documents should be produced that: • Mandate the exact procedures that staff are required to …
Unknown
10 — Consistent excess motion specification
Recommendation: Network Rail Company Standards RT/E/C/11772, RT/E/C/11210 and/or associated drawing BRS-SM 2370/2 & /8 should be modified so that they are consistent in respect of the specification for excess motion setting and of the terminology used.
Unknown
8 — Flangeway gap standards
Recommendation: Railway Group Standard GI/RT7004 and all Network Rail technical documents covering installation, inspection and maintenance of point flangeway gaps, including the opening at the switch toes, should be reviewed, and, where necessary, modified, in order to: • Use consistent terminology. …
Unknown
71 — Review of pipeline emergency procedures
Recommendation: Operators should be required by regulation regularly to review pipeline emergency procedures and manuals. The review should ensure that the information contained in manuals is correct, that the procedures contained are agreed with those who are responsible for executing them …
Unknown
11 — BNFL safety precautions and procedures
Recommendation: BNFL should do more, in future, to ensure that safety precautions and operating procedures at Windscale are sufficient for all eventualities, are strictly observed and are continually rehearsed. (para 11.11.)
Unknown
Prevention of Future Deaths reports(68)— showing 50 strongest matches
Ryan Chapman
Concerns: The coroner identified staff's lack of understanding regarding the patient leave policy and the role of support workers as escorts. Concerns were also raised about overdue risk assessments, insufficient information provided to families, and inconsistent visitor security on the ward.
Overdue
Kevin Pearson
Concerns: The coroner noted that the company may not yet have ensured full compliance with relevant health and safety guidance, nor confirmed all drivers' awareness and understanding of it.
Overdue
Doris Taylor
Concerns: The coroner noted the need for staff training on what constitutes a reportable incident and for managers to be aware of their duty to report. Concerns were also raised regarding the safety and appropriate strength of door-closers to prevent injury.
Overdue
Rajesh Parkash
Concerns: The coroner identifies gaps in ensuring staff awareness of policy updates and comprehensive driving regulations for multi-lane highways. Concerns also include the need to expand supervising paramedic roles to include driving, ensure ongoing driver training, and improve communication within and between ambulance services.
Overdue
Seweryn Glowinski
Concerns: The coroner identified a lack of communication between prison units regarding a prisoner's transfer plan and risk assessment. Documentation for detention contained errors due to copying, and senior managers were unaware of rules for transferring ACCT prisoners to segregation.
Overdue
John Lowe
Concerns: The coroner noted a belief amongst nursing staff that 1:1 care could only be provided for a patient's mental health needs, rather than for their physical care needs or falls risk.
Overdue
Austen Harrison
Concerns: Insufficient health and safety training for managers regarding their responsibilities and a lack of understanding of roles across the company were noted. The coroner also raised concerns about the absence of regular health and safety audits by qualified professionals.
Response (Hugo Boss): • Hugo Boss re-launched enhanced health and safety training for managers in February 2015, introducing a new Health and Safety Management Workbook, and will launch an e-learning module in August … (AI summary)
Responded
Mark Groombridge
Concerns: Concerns were raised about the lack of direct communication between local offender managers and clinicians before issuing recall paperwork for hospitalized offenders, and confusion among probation staff regarding the correct recall process.
Response (HM Prison and Probation Service): • Probation Instruction 07/2013 was replaced by Probation Instruction 27/2014, which was updated in February 2015. • Deputy Directors will ensure all probation staff are reminded of recall procedures by … (AI summary)
Responded
Bruce Longden
Concerns: The coroner noted that Sussex Partnership Trust appeared unaware of their own protocols regarding City City.
Responded
Gail Prentice
Concerns: The coroner noted there is no formal requirement for surgeons to acknowledge they have read and understood relevant hospital guidelines and those from bodies like NICE.
Overdue
Arthur Fry
Concerns: A communication breakdown meant an MRI scan was declined due to an uncommunicated consent requirement, potentially impacting the patient's care. Tighter controls are needed for requisitioning procedures like MRI and CT scans to avoid confusion and prevent failed procedures.
Response (University Hospitals North Midalnds NHS Trust): • Radiographers now document the name of the accompanying nurse and explicit instructions for the ward clinical team in the electronic CRIS system. • The Trust is in the process … (AI summary)
Responded
Douglas Birch
Concerns: Prison officers were either unaware of or did not follow the requirement to elicit a response from prisoners when unlocking cells, and they were also not consistently receiving or reading Prison Service Orders.
Response (HM Prison and Probation Service): • A notice to staff was issued at HMP Swaleside on 10 August 2015, setting out local procedures for mandatory welfare checks and requiring staff and supervising officers to sign … (AI summary)
Responded
Lee Gaunt
Concerns: The coroner identified ineffective Occupational Health support and delays in accessing a doctor. Concerns were also raised about the Fire and Rescue Service requiring the deceased to take on extra duties despite knowing he was suffering, indicating insufficient support for staff in stressful situations.
Response (Lee Gaunt): • The Fire and Rescue Service (FRS) provided feedback on the inquest outcome and concerns to its current occupational health providers. • The FRS is piloting a Trauma Risk Management … (AI summary)
Responded
Maureen Flynn
Concerns: The coroner noted a falls risk assessment for Mrs. Flynn was incomplete, and care staff were unaware. The report identifies a need for a system to alert staff to incomplete assessments, an issue also not identified by the patient safety investigation.
Response (Stockport NHS Trust): • The Trust stated that falls risk assessments were completed in line with Trust policy. • The Trust shared the investigation findings via a ward newsletter in June 2016. • … (AI summary)
Responded
Warren Sampson
Concerns: The coroner noted inconsistent Healthcare attendance and documentation in ACCT reviews, a lack of process for following up missed first-night healthcare screenings, and no system to ensure officers are familiar with local directives.
Response (Care UK): • Healthcare staff are now invited to ACCT reviews daily, and their input is recorded in ACCT documents and SystmOne. • A second health screen is now undertaken within 72 … (AI summary)
Overdue
Wayne Cornlouer
Concerns: The coroner noted that Night Orders now include a medical emergency coding system (code red/code blue) but raised concerns about whether all staff are aware of this change.
Response (HM Prison and Probation Service): • The Notice to Staff regarding emergency codes and ambulance requests was re-issued on 28 September 2016, and the local emergency code protocol was distributed and displayed. • Existing staff … (AI summary)
Responded
John Williams
Response (Care UK): • The nurse involved in the self-harm recording has received further reassurance, support, and guidance. • A register is now maintained for uncompleted Second Reception/Wellman assessments, with the Lead Nurse … (AI summary)
Overdue
Dominic White
Concerns: The coroner noted a lack of a robust protocol to ensure all relevant personnel are aware of documented mental health observation levels. Concerns were also raised about insufficient recognition of risks when allowing a patient, under Mental Health Act detention, to leave the hospital.
Response (Whittington Hospital NHS2 Trust): • Whittington Health and Camden & Islington NHS Foundation Trust are updating mental health policies to clarify roles and responsibilities for patient observation levels. • Signage has been introduced in … (AI summary)
Overdue
Charlotte Agnew
Concerns: The coroner noted insufficient suicide risk assessment, no comprehensive care plan, and ineffective transfer of care prior to discharge from psychiatric services. Concerns also included delayed urgent assessments and medication recommendations without a psychiatrist's review.
Overdue
Rosalind Flett
Concerns: The Trust's search policy contained ambiguity between 'advanced' and 'intimate' searches, leading staff to believe they could not ask patients to remove outer clothing like a bra for searching. This policy gap may extend to other Trusts.
Overdue
Agnes Lambert
Concerns: The coroner noted that senior staff did not insist on a nurse moving wards despite a patient's fixation, which later contributed to an incident. Additionally, there was an unacceptable four-month delay in conducting witness interviews for a subsequent disciplinary hearing.
Response (Camden and Islington NHS Trust): • The Trust has appointed a permanent ward manager and is implementing "vital conversations" training for line managers to support challenging staff conversations. • The disciplinary policy is under review … (AI summary)
Responded
Austin Thomas
Concerns: The coroner identified a concern about potential driver distraction from high-volume music in heavy machinery and the lack of a policy on its use. The report also notes the absence of random drug testing for heavy machinery operators.
Overdue
Mary Chapman
Concerns: Nuffield's discharge policy is lengthy, generic, and lacks clear definition of roles and responsibilities for staff or guidance for arranging post-discharge investigations. There was insufficient evidence that implemented changes had improved the quality or accuracy of discharge communications.
Response (Nuffield Health): • Nuffield Health revised its national discharge policy to clarify roles, responsibilities, and processes for critical post-discharge investigations. • Communications were issued to all medical personnel, including consultants and Resident … (AI summary)
Responded
Ricky Barcock
Concerns: The coroner raises concerns regarding the appropriateness of the client wellbeing checks protocol, specifically concerning physical checks during sleep, after drug use, and the need to rouse clients to confirm their wellbeing.
Response (Oasis Recovery Communities): • Oasis Bradford reviewed and updated its Observation and Client Wellbeing Checks Policy in December 2019, expanding its explanation and explicit instructions. • Related risk assessments, policies, and procedures were … (AI summary)
Overdue
Theresa Robertson
Concerns: The surgery lacked documentary records of critical telephone calls and a consultation regarding a high-risk patient's prescription. A doctor acted outside surgery guidance for prescription length, and no audit was undertaken to identify other similar instances.
Overdue
Michael Dent-Jones
Concerns: Staff at St Catherine’s Priory and other Approved Premises may not be familiar with or applying the Safe Working Practices Document, specifically the guidance on prescribed medication delivery/collection and other resident safety policies.
Response (HM Prison and Probation Service): • The Head of the National Approved Premises Team undertook an audit of all Safe Working Practices (SWPs) to ensure they contained correct local information regarding residents' prescribed medication. • … (AI summary)
Responded
Shirley Froggett
Concerns: The coroner was not satisfied that New Lodge Nursing Home had robust systems in place to ensure compliance with care plans, policies, and protocols.
Overdue
Valmai West
Concerns: Concerns were raised regarding inadequate staffing levels in the Royal Gwent Hospital Emergency Department, which led to staff not following hospital protocol and NICE guidance on the frequency of patient observations. This issue is described as a frequent and ongoing problem.
Response (Aneurin Bevan University Health Board): • The Health Board undertook a review of nurse staffing levels following receipt of the report and confirmed that staffing at the time of the incident was appropriate and adequate. … (AI summary)
Responded
Henry Holcombe
Concerns: The coroner noted staff non-compliance with the Trust's therapeutic engagement and observation policy, specifically regarding night-time observations of patients believed to be sleeping. This issue has recurred over time despite previous incident reports.
Response (Sussex Partnership NHS Trust): • The Trust confirmed it had strengthened internal monitoring arrangements and enhanced staff training provision, including for agency and bank staff. • Policy compliance is now reviewed weekly by Ward … (AI summary)
Responded
Cpl Ryan Lovatt
Concerns: The coroner noted concerns that the alcohol policy for Op Cabrit was not realistic, workable, or widely understood, and that the "shark watch" role, intended to ensure soldier vigilance, was not formalised or effectively implemented.
Response (Ministry of Defence): • The Ministry of Defence replaced the '2-can rule' with impact criteria focusing on the negative effects of alcohol consumption. • An education programme regarding the consequences of excessive alcohol … (AI summary)
Responded
Robert Hammond
Concerns: The coroner noted that Working with Risk documentation was not completed during the initial nine contacts with Mr Hammond, which resulted in an unsatisfactory care plan.
Response (Coventry and Warwickshire Partnership NHS Trust): • The Trust completed an audit of risk assessment within its Urgent Care Services. • The Trust committed to providing bespoke training for staff and implementing a standardised monthly audit … (AI summary)
Responded
Kyle Nel
Concerns: The coroner raises concerns about the lack of a structured approach for recording and responding to family concerns regarding a prisoner's welfare, and the need to review security fences preventing the transfer of prohibited items between prison units.
Response (HM Prison and Probation Service): • HMP Guys Marsh has established multiple channels for families to raise concerns, including direct contact with the Safer Custody team and an out-of-hours orderly officer. • All family concerns … (AI summary)
Responded
Mark Castley
Concerns: The coroner identified that risks of recurrent impulsive self-harm in specific situations were not fully assessed for the period after sentencing. There was uncertainty whether this was due to policy requiring imminent risk or its misinterpretation.
Response (HM Courts and Tribunals Service): • HM Courts and Tribunals Service (HMCTS) conducted a thorough review of its procedures for managing the risk of self-harm by defendants in court. • The review identified and approved … (AI summary)
Response (HM Prison and Probation Service): • Appendix 1 of the ‘Working with Suicide & Self-Harm’ guide was reviewed, and a question on suicide risk was updated. • The Probation EQUiP process map for court staff … (AI summary)
Responded
Jake Cahill
Concerns: The coroner noted no evidence that sensitive issues in a self-assessment form were discussed with Jake by a professional before completion. Youth Justice Board guidance also lacks express reference to considering such discussions with vulnerable young persons.
Response (Youth Justice Board for England and Wales): • The Youth Justice Board wrote to all youth justice services, reminding them of key principles for conducting AssetPlus self-assessments with children. • The Youth Justice Board committed to reviewing … (AI summary)
Responded
William Savory
Concerns: There was a delay in initiating the missing persons protocol, and some staff were not aware of the requirement to commence procedures immediately for informal patients, creating a risk of future delays.
Overdue
Khalid Abiaz
Concerns: The coroner noted inadequate ACCT training at HMP Swansea, leading to a lack of understanding among prison officers about warning markers that require opening an ACCT. This creates a risk due to infrequent training and inconsistent interpretation of mandatory policy guidance.
Response (HM Prison Probation Service): • A new version of ACCT training, which includes ACCT v6, has been produced. • Fifteen staff members in reception, induction, and healthcare received the new training module in July … (AI summary)
Response (Swansea Bay University Hospital): • Eight prison health staff have completed version 6 ACCT training, and two slots per ACCT training session will be ring-fenced for Health Board staff. • Health Board bank staff … (AI summary)
Responded
Liridon Saliuka
Concerns: The coroner noted a lack of clear documentation regarding required disability adjustments for the prisoner and insufficient disability awareness among prison staff.
Response (Oxleas NHS Foundation Trust): • Disability adjustments for patients will now be documented on the Prison Nomis (P-Nomis) system, accessible by HMP Belmarsh, Royal Borough of Greenwich Social Care, and Oxleas NHS Foundation Trust. … (AI summary)
Response (HM Prison and Probation Services): • HMPPS stated that Prison Service Instruction 32/2011 mandates the identification and recording of prisoner disabilities. • HMP Belmarsh will hold monthly training sessions throughout 2023 for operational staff on … (AI summary)
Responded
Doris Smith
Concerns: The coroner noted delays and inaccuracies in falls risk assessments, a confusing observation policy, and a lack of required neurological observations. Concerns were also raised about poor electronic record keeping and communication between staff.
Response (Essex Partnership University): • The Trust has implemented weekly audits of admission checklists and uses clinical dashboards to monitor the completion of falls risk assessments within 24 hours. • The Trust is developing … (AI summary)
Responded
Gillian Baumgardt
Concerns: The coroner noted the absence of a system requiring radiographers to ensure pre-exposure markers are present in x-rays, and a lack of a system for radiologists to investigate inconsistencies in injury sites between images before finalising reports.
Response (North Bristol NHS Trust): • A 'buddy check' system for electronic markers in trauma radiographs was introduced in December 2023, and a daily audit for trauma hip radiographs commenced in March 2024. • New … (AI summary)
Responded
Daniel Tucker
Concerns: The coroner identifies that some staff do not fully utilise ward-specific risk assessments and care plans. Also, the system for allocating and recording named nurses is inadequate, hindering investigations into their role.
Response (NHS England): • Specific training and a new protocol were developed for first party callers in crisis. • NHS England issued guidance for Ambulance Services on overdoses and suicidal intent in April … (AI summary)
Response (Ofcom): • Ofcom contacted the online service on 7 November 2023 and 8 January 2024 regarding its accessibility to UK users. • Ofcom is implementing the Online Safety Act 2023, which … (AI summary)
Response (Nottinghamshire Healthcare NHS Foundation Trust): • The Trust conducts monthly audits of care planning compliance and has initiated a rapid improvement programme focused on care planning, risk assessment, and patient engagement. • Clinical risk and … (AI summary)
Response (Department of Health and Social Care): • NHS England has issued and updated guidance for Ambulance Services on overdoses and suicidal intent, and specific training and protocols have been developed for first-party callers in crisis. • … (AI summary)
Responded
Giuseppe Tabone and Andrew Evans
Concerns: The coroner raises concerns about prison staff at HMP Lewes failing to carry out required roll checks, noting confusion over requirements and a lack of understanding of their importance. There are also insufficient measures to monitor staff compliance with these checks.
Response (HM Prison and Probation Service): • HMP Lewes reviewed its Local Operating Procedure on roll checks in August 2023 and issued notices to staff. • The prison is reviewing roll checks to align with new … (AI summary)
Responded
Cariss Stone
Concerns: The coroner noted staff misunderstandings regarding the level two observation policy and concerns about agency staff training. There was also a lack of routine supply of ligature cutters to observation staff in a ward where self-harm was not uncommon.
Response (Somerset NHS Foundation Trust): • The Trust revised its patient observation policy in May 2024 to provide greater clarity and improved clinical governance, including specific guidance for level 2 intermittent observations. • All staff … (AI summary)
Responded
Ash Bannister
Concerns: The coroner identified a lack of documentation for the removal of Ash's ligature risk assessment and a policy gap for "ad hoc" waking night cover, which led to an 11-hour period without checks. Concerns were also noted regarding insufficient communication of historic risks between care homes.
Responded
Neville Abbott
Concerns: A lack of knowledge and use of the "Professionals Checklist" by Adult Social Care practitioners meant individuals at risk of self-neglect were not assessed, and Multi-Agency Risk Management Meetings were not considered.
Response (BCP Council): • BCP Council undertook a review of care and support and made changes to how it supports individuals who find engaging with services challenging. • The Council instructed all operational … (AI summary)
Responded
Samantha Angel
Concerns: The coroner highlighted delays in a work investigation and how easily allegations against the deceased became public among colleagues. There were also concerns that the distress caused by this should be a factor in accelerating the investigation's conclusion.
Response (Portsmouth Hospitals): • The Trust has refreshed HR leadership, established reporting metrics for HR casework, and introduced a Protected Time Agreement and Protocol for Investigating Officers. • A new message has been … (AI summary)
Responded
Sean O’Connor
Concerns: The coroner noted that despite a risk assessment requiring lone workers to request checks, this did not occur. There was an identified opportunity to integrate a reminder about requesting checks into routine daily discussions with workers on site.
Response (Canary Wharf Management): • Canary Wharf Management reviewed its procedures for lone workers. • Canary Wharf Management will trial a new system feature for Work Authorisations, beginning July 2024, to include a mandatory … (AI summary)
Responded
Donna Smith
Concerns: The coroner identified a lack of formal policies and guidance defining responsibilities between CCTV operators and West Mercia Police, leading to delays in calling emergency services. A relevant agreement remained uncompleted over a year later.
Response (West Mercia Police): • West Mercia Police withdrew Airwave Radio from CCTV rooms. • All contact from CCTV operators is now received via telephony, allowing for the automatic creation of a Contact Record. … (AI summary)
Response (Wychavon District Council): • Wychavon District Council implemented a new policy for its CCTV operatives to clarify procedures for contacting emergency services. • The policy specifies that operatives will call 999 for visible … (AI summary)
Responded
Jada Monoja
Concerns: The coroner identified that the online Risk Assessment Tool (EPJS) is not used in line with policy, with detailed indicators not being systematically reviewed. This can lead to risk assessments based on incomplete or misleading information.
Response (NHS England): • NHS England included its position regarding risk assessments in its April 2024 guidance for mental health inpatient services. • Oxleas NHS Foundation Trust designed a clinical risk training workshop … (AI summary)
Response (Department of Health and Social Care): • The Department noted the publication of updated National Institute for Health and Care Excellence (NICE) guidance in September 2022 on self-harm assessment, management, and prevention. • The Department noted … (AI summary)
Response (South London and Maudsley NHS Trust): • The Trust appointed leads and secured a pilot site role to adapt its risk assessment and formulation tool with the National Culture of Care team. • The Trust will … (AI summary)
Responded
Clara Winter
Concerns: The coroner noted that significant learning identified by the Health Board, regarding timely escalation and fluid balance charting for surgical nurses, has not been fully rolled out due to resourcing issues and its non-compulsory nature.
Response (Cwm Taf Morgannwg University Health Board): • The 'Acutely Unwell Patient' course will be standardised and available on the Electronic Staff Record (ESR) from September 2024, with increased monthly training capacity. • Outreach staffing will reach … (AI summary)
Responded
Susan Edwards
Concerns: The coroner identified a lack of a system at Worcestershire Royal Hospital to ensure instructions for mechanical thromboprophylaxis are carried out, noting an instruction was not entered on a patient's drug card and consequently not actioned for 18 days.
Response (Worcestershire Acute Hospitals NHS Trust): • The Trust stated it would implement a 'Lesson of the week' to educate staff on prophylaxis and the requirement to sign prescription charts. • Anti-coagulation nurses are to provide … (AI summary)
Responded
Select committee recommendations(146)— showing 50 strongest matches
#66 —
Recommendation: Given the impact of uncertainty in the planning system on the delivery of new homes, the Government should ensure that policy is communicated clearly and in a timely manner. For a transition period to be successful stakeholders need to know …
Response attribution not verified
#48 —
Recommendation: HMRC must publish guidance to help employers and businesses understand exactly what data they need to provide as early as possible in 2024.
Response attribution not verified
#39 —
Recommendation: Detailed guidance on subcontracted R&D, including realistic examples, must be available to businesses in advance of 1 April 2024 when some businesses will have to apply the new rules. HMRC needs to assure businesses that final guidance will be available …
Response attribution not verified
#47 —
Recommendation: We ask the Government, whether in conjunction with the proposed duty to inform workers of their right to join union or in separate legislation, to introduce a duty for employers to inform their employees of their workplace rights and, in …
Response attribution not verified
#46 —
Recommendation: We consider that, in addition to the introduction of a duty to inform all employees of their right to join a union, there is a compelling case for introducing a wider duty on employers to inform employees about the most …
Response attribution not verified
#40 —
Recommendation: Some employers appear to have a poor understanding of the rights of disabled people in the workplace and how to uphold them.
Response attribution not verified
#33 —
Recommendation: The Government should provide guidance for courts , focusing on the treatment of interpreters. Guidance should ensure that interpreters’ key role in court proceedings is recognised, and that HMCTS provides information about cases ahead of time, in order to improve …
Response attribution not verified
#31 —
Recommendation: We found that in some cases interpreters are not treated as professionals working within the court and are not considered key members in the running of the court. Interpreters are treated like members of the public and not kept up …
Response attribution not verified
#54 —
Recommendation: The government must ensure that local authorities understand the need for robust independence of IROs, making clear through relevant guidance that victimisation must never be tolerated. (Recommendation, Paragraph 257)
Response status not verified
#7 —
Recommendation: To ensure that disabled children and their families are aware that they are entitled to an assessment of their needs, the duty on local authorities to provide one should be clear and explicit. We agree with the Law Commission’s recommendation …
Response status not verified
#5 —
Recommendation: The disabled children’s social care framework is complex and difficult to navigate. In line with the Law Commission’s recommendations, we agree that there should be a single, comprehensive piece of statutory guidance on disabled children’s social care law, clearly setting …
Response status not verified
#31 —
Recommendation: It is very disappointing that Border Force officers did not receive guidance on the implementation of new regulations until less than one working day before they came into force. Without enough time to raise questions and properly to digest the …
Response attribution not verified
#26 — Code of Practice for resident communication during remediation shows inconsistent practice and limited awareness
Recommendation: 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 …
Response attribution not verified
#26 —
Recommendation: We welcome the Cabinet Secretary’s commitment to provide further guidance to clarify that civil servants in the devolved administrations should work and spend public funds exclusively on matters within devolved competence. If the permanent secretaries in Scotland or Wales are …
Response attribution not verified
#3 —
Recommendation: We were told that ministers were not sufficiently aware of the extent of their influence over appointments, or the limits on it. It is incumbent upon permanent secretaries to brief incoming ministers on the degree to which they can be …
Response attribution not verified
#37 —
Recommendation: Given the range of commercial arrangements relating to R&D activity, we consider that defining ‘subcontracted R&D’ to exclude what the Government calls a ‘normal’ contract may be very challenging, if not impossible. We therefore agree that it is vital that …
Response attribution not verified
#48 —
Recommendation: When developing an information hub setting out support for young disabled people during the transition from education to work the Government should ensure that workplace rights are prominently highlighted.
Response attribution not verified
#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 status not verified
#2 —
Recommendation: The Committee recognise that Covid-19 has required an immediate and unprecedented response and praise the probation staff and offenders for adapting to the current situation. The Committee are aware that the NPS and CRCs may differ in their models of …
Response attribution not verified
#15 —
Recommendation: 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 …
Response attribution not verified
#14 —
Recommendation: In 2021, the Department acknowledged publicly concerns about excessive levels of noise and vibration on the Ajax vehicles. The Department admitted that because of shortcomings with its safety processes, which made it complicated to raise issues, it had injured some …
Response attribution not verified
#3 —
Recommendation: The failure to escalate and address noise and vibration issues in a timely manner shows that the Department must simplify its over-complex safety processes and change behaviours. The Department acknowledges that it has injured some soldiers, which it rightly describes …
Response attribution not verified
#83 — Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
Recommendation: The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with …
Response attribution not verified
#82 — Guidance on delegating healthcare responsibilities within schools remains weak and unclear.
Recommendation: Guidance on the delegation of healthcare responsibilities within schools and multi-academy trusts remains weak. There is insufficient clarity on how and when healthcare tasks can be appropriately and safely assigned to school or multi-academy trust staff, what training and safeguards …
Response attribution not verified
#80 — Utilise NICE expertise to produce new evidence-led SEND guidelines and intervention pathways.
Recommendation: Bringing education and health more closely together should be supported by an evidence led approach, drawing on the role of NICE (National Institute for Health and Care Excellence) to produce new SEND guidelines and intervention pathways. (Recommendation, Paragraph 277)
Response attribution not verified
#51 — Provide comprehensive training within ITT and clear guidance for inclusive education practices.
Recommendation: The Department should provide comprehensive training within ITT and clear guidance for schools, multi-academy trusts and education staff on delivering inclusive education practice. This will ensure that all settings understand their legal obligations and are equipped to make the necessary …
Response attribution not verified
#9 — Inconsistent SEN support and provision leads to inequitable experiences for children with SEND.
Recommendation: The current inconsistency in SEN support and ordinarily available provision across England is unacceptable and results in deeply inequitable experiences for children and young people with SEND. The lack of consistent good practice in SEN support, driven by insufficiently clear …
Response attribution not verified
#30 — Ensure schools implement clear policies and teacher training to tackle anti-Muslim hate.
Recommendation: The Government should ensure that schools have clear policies in place for tackling anti-Muslim hate. This needs to include specific training for teachers on the ways in which gendered Islamophobia manifests in society to ensure that teachers are equipped to …
Response attribution not verified
#14 — Afghan relocation unit reported 49 data breaches between 2021 and 2025.
Recommendation: In August 2025, the Department reported that there had been 49 separate data breaches between 2021 and 2025 at the unit handling applications from Afghan citizens to relocate to the UK. Of these, the Department assessed that seven met the …
Response attribution not verified
#180 — Inconsistent deployment of security measures undermines their effectiveness against criminal networks
Recommendation: Our observations confirmed that existing security measures, such as sniffer dogs, are often deployed in an inconsistent manner. For example, drug detection dogs being used for only a few instances in a day in some prisons, rather than as part …
Response attribution not verified
#63 —
Recommendation: We were disappointed to learn of the Government’s decision to not consult on nutrient and water neutrality guidance despite time being available. This choice was unnecessary and led to serious ramifications. It is indicative of a wider issue: communication on …
Response attribution not verified
#25 —
Recommendation: We recognise that the arrangement whereby senior civil servants in Scotland and Wales are accountable to the Scottish or Welsh government but are line managed by the Head of the UK civil service has the potential to cause confusion about …
Response attribution not verified
#39 —
Recommendation: The Government should introduce a four-week deadline within which employers are obliged to respond to an employee’s request for a reasonable adjustment. The Government should explore the means by which compliance with the deadline could be monitored and enforced, both …
Response attribution not verified
#38 —
Recommendation: We recognise the need for a clear timeframe for responding to a request for a reasonable adjustment. However, we consider that, taking into account the day-to-day pressures on businesses and employers, four weeks would be a more appropriate deadline than …
Response attribution not verified
#37 —
Recommendation: The review of the National Protocol on Reducing Unnecessary Criminalisation of Looked-After Children and Care Leavers is a welcome step, although its publication is already late. The government should consider placing it on a statutory footing, to ensure that local …
Response status not verified
#37 —
Recommendation: We urge the government to make both Local and National Listed Building Consent Orders a standard and accessible route for the approval of low- risk and routine heritage works by supporting Local Planning Authorities to consider their immediate adoption. This …
Response status not verified
#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 status not verified
#12 —
Recommendation: We remain uncertain about the capacity in which the DNSA was giving evidence, and the extent to which civil servants can act as witnesses of fact on matters that are not made explicit by government policy. (Conclusion, Paragraph 78)
Response attribution not verified
#27 —
Recommendation: We recommend that the Government work with the industry to identify and resolve any potential confusion, including, if necessary, by redefining the role of principal designer intended under the proposed new dutyholder regime. We also recommend that the role be …
Response attribution not verified
#26 —
Recommendation: We are persuaded that the role of principal designer in the CDM regulations differs from the one envisaged for the new dutyholder regime and that this could cause confusion in the industry.
Response attribution not verified
#18 —
Recommendation: Demands on the civil servants working on the Covid-19 pandemic response and/or EU Exit have been high at a time when many are having to adjust to new ways of remote working.48 The Cabinet Office believes that morale across staff …
Response attribution not verified
#17 —
Recommendation: The Department said that Ajax’s safety problems had highlighted broader issues around noise-induced hearing loss, which formed the largest number of claims in the armed forces compensation scheme. It has commissioned the vice-chief of the defence staff and the second …
Response attribution not verified
#15 —
Recommendation: In June 2021 the Department commissioned David King, its Director Health, Safety and Environmental Protection, to assess whether correct health and safety procedures had been followed. His report, published in December 2021, concluded that collective failings enabled activity to continue …
Response attribution not verified
#40 —
Recommendation: Following the House administrations being three months late sharing information about a recent asbestos incident, the Clerk of the House acknowledged staff should have been notified earlier.108 We heard relevant trade union representatives were informed on 15 February, five days …
Response attribution not verified
#21 —
Recommendation: The incident was formally reported to the Health and Safety Executive on 10 February 2022, with relevant trade unions informed on 15 February. The Clerk of the House of Commons acknowledged that the staff affected should have been contacted with …
Response attribution not verified
#20 —
Recommendation: The Clerk of the House of Commons explained the House administrations stood down all works on the parliamentary estate on 9 February, in part to check whether the right protocols were in place and understood by the relevant staff.50 He …
Response attribution not verified
#5 —
Recommendation: To date, there has been a failure of transparency and accountability over work to restore and renew the Palace. This includes: the House administrations being three months late sharing, in line with expected standards, information on a recent asbestos incident …
Response attribution not verified
#8 —
Recommendation: We recommend that the Government, in consultation with the Menopause Ambassador, produces model menopause policies to assist employers. The model policies should cover, as a minimum: how to request reasonable adjustments and other support; advice on flexible working; sick leave …
Response attribution not verified
#4 —
Recommendation: If Mr Thompson’s assertion is correct—namely, that there are errors in applying company policy at Royal Mail—then these would appear to be widespread, and we can only conclude that the level of management oversight at Royal Mail is negligent and …
Response attribution not verified
#3 —
Recommendation: Mr Thompson asserts that the evidence we presented to him was due to failures to apply company policy. However, we do not believe that such widespread errors in applying company policy could happen without the direct or indirect approval of …
Response attribution not verified
HSSIB safety recommendations(28)
Medication not given: anticoagulation before and after a procedure
How does your organisation support staff to find and readily access anticoagulation related guidelines?
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
Healthcare providers are required to reduce the instances and risk of hospital acquired infections. The introduction of non-ported cannulae was not effectively communicated to end users and this affected the introduction of these items.
Learning Prompt
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 …
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
Greater attention and focus are given to the Sign In and Time Out phases of the WHO checklist compared to Sign Out. The Sign Out process appears to compete with other tasks and processes and is often rote-learned and anticipated. …
Learning Prompt
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Guidance In response to the changing situation and developing understanding of risks during the first wave of the COVID-19 pandemic, a large volume of rapidly changing guidance was produced. Despite best efforts to make this accessible to staff, investigations found …
Learning Prompt
Clinical decision making: diagnosis of pulmonary embolism in emergency departments
It may be beneficial for individual organisations to understand the extent to which national guidance on the diagnosis and management of pulmonary embolism is implemented across their organisations. This would help to identify local barriers to implementation to address. In …
Safety Observation
Care delivery within community mental health teams
It may be beneficial for mental health organisations to ensure their Early Intervention in Psychosis referral process is in line with the national guidance, and that staff are clear about the upper age limit of patients accepted onto the pathway.
Safety Observation
Sepsis: a patient with abdominal pain
There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.
Area of Improvement
Sepsis: a patient with abdominal pain
Staff perceive that a diagnosis of infection is needed before completing the sepsis screening tool.
Area of Improvement
Medication not given: anticoagulation before and after a procedure
Does your organisation have processes in place to ensure that when new evidence on newer anticoagulants becomes available it is considered for inclusion in local guidance as soon as possible?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
Does your organisation have a process for ensuring that guidelines that cross-refer to other relevant guidelines are reviewed together to ensure they provide consistent advice?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
Who in your patient pathway is responsible for prescribing time critical medications?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
Who in your patient pathway is responsible for identifying patients who need time critical medications?
Learning Prompt
Wrong patient details on blood sample
Trusts can ensure that local policies and training on blood sampling account for the challenges posed by different working environments.
Learning Prompt
Delayed recognition of acute aortic dissection
Current recommendations for all patients with acute aortic dissection specify immediate measures to control blood pressure and heart rate. Non-specialist hospitals which may dispatch these patients to specialist centres might wish to review their guidance and instructions to staff in …
Safety Observation
Wrong site surgery – wrong patient: invasive procedures in outpatient settings
It would be beneficial if it was easier for trusts to find clear national guidance on what a good patient identification check looks like to assist the quality and consistency of trust guidance.
Safety Observation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
HSIB recommends that future iterations of the Royal College of Obstetricians and Gynaecologists’ guidance clarify the management of a reported change in fetal movements during the third trimester of pregnancy with due regard to national policy.
Safety Recommendation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
HSIB recommends that NHS England and NHS Improvement leads work to develop a process to ensure consistency and clarity across national maternity clinical guidance.
Safety Recommendation
Mental health inpatient settings: Supporting safe care during transition from inpatient children and young people’s …
HSSIB recommends that NHS England reviews and revises its guidance and policies to ensure consistency regarding the language used for age ranges (for example children, young people, young adults and adults). This is to support a consistent approach to healthcare …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Do your staff know who are the recipients of and users of your discharge correspondence, particularly discharge summaries?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure messages about the care pathway are effectively shared and understood by staff across different organisations?
Learning Prompt
Never events: analysis of HSIB's national investigations
It is recommended that the Centre for Perioperative Care reviews and revises the National Safety Standards for Invasive Procedures (NatSSIPs) policy to increase standardisation of safety critical steps that are common across all procedures.
Safety Recommendation
Access to critical patient information at the bedside
It may be beneficial if the language used to refer to cardiopulmonary resuscitation recommendations is standardised and clarified through the implementation of the Recommended Summary Plan for Emergency Care and Treatment.
Safety Observation
Access to critical patient information at the bedside
HSIB recommends that the Resuscitation Council UK clarifies and promotes expectations around the sharing, presentation, and language of cardiopulmonary resuscitation recommendations in hospital ward environments in line with the findings of this investigation.
Safety Recommendation
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 …
Safety Observation
Sepsis: a patient with abdominal pain
There is limited understanding and awareness of processes to support family and carer involvement in clinical decision making about deterioration.
Area of Improvement
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
Do your staff recognise that capacity and resource issues in primary and community care mean time-critical actions after discharge may be delayed or unable to be actioned?
Learning Prompt
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.
Area of Improvement
NCEPOD recommendations(13)
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
CQC inspection actions(387)— showing 50 strongest matches
William Harvey Hospital
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy.
Should Do
William Harvey Hospital
The trust should ensure they follow their Standard Operating Procedure when placing patients in escalation areas.
Should Do
William Harvey Hospital
The trust must ensure radiology staff use the World Health Organisation checklist before each radiology intervention
Must Do
William Harvey Hospital
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Must Do
Westmorland General Hospital
The trust should ensure that all staff follow infection control principles, including the use of personal protective equipment (PPE) at all times and receive refresher training in this where deemed necessary.
Should Do
Westmorland General Hospital
The service must ensure staff have access to up-to-date and evidence-based guidelines and policies.
Must Do
Westmorland General Hospital
The service must ensure staff have access to up-to-date and evidence-based guidelines and policies.
Must Do
Westmorland General Hospital
The trust must ensure that staff in the service adhere to trust infection prevention and control policy in the use of personal protective equipment and maintain patient and staff safety through social distancing at all times and in all areas.
Must Do
Westmorland General Hospital
The service must ensure staff have access to up-to-date and evidence-based guidelines and policies.
Must Do
Wavertree Bungalow
We recommend consent for the use of assisted technology is obtained for people in line with the law and guidance.
Should Do
University Hospital of Hartlepool
The trust should ensure that policies and procedures are correctly managed and reviewed in a timely way so that the latest and most appropriate guidance is always available to its staff.
Should Do
University College Hospital & Elizabeth Garrett Anderson Wing
The service should ensure that all staff adhere to the uniform policy to maintain effective infection prevention control.
Should Do
The York Hospital
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must Do
The York Hospital
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must Do
The York Hospital
The trust must ensure that the guidance within all policies is up to date, accurate and relevant to the service. This includes, but is not limited to, the guidance within the workforce and equality, diversity, and inclusion (EDI), freedom to …
Must Do
The Ipswich Hospital
The service should ensure that safety champion roles and responsibilities are clear to maternity staff and they are involved in the process.
Should Do
South Tyneside District Hospital
The trust must ensure staff complete the WHO safety checklist when required, and ensure this is recorded, monitored, and audited with actions taken to improve compliance.
Must Do
South Tyneside District Hospital
The trust must ensure staff understand and work within the requirements of the Mental Capacity Act 2005 whenever they work with people who may lack the mental capacity to make specific decisions.
Must Do
South Tyneside District Hospital
The trust must ensure staff understand and work within the requirements of the Mental Capacity Act 2005 whenever they work with people who may lack the mental capacity to make specific decisions.
Must Do
Scarborough Hospital
The service should ensure the service does not contravene their SOP for the care and treatment of patients whilst in an ambulance.
Should Do
Scarborough Hospital
The trust must ensure that effective systems are in place to ensure staff adhered to the Mental Capacity Act.
Must Do
Scarborough Hospital
The service must ensure all staff are aware of and consistently follow the trust policy to safely store medicines including controlled drugs.
Must Do
Scarborough Hospital
The service must ensure managers monitor the service’s use of Deprivation of Liberty Safeguards and ensure staff know how to complete them. Managers must also monitor how well the service follows the Mental Capacity Act and how they would make …
Must Do
Scarborough Hospital
The trust must ensure that effective systems are in place to ensure staff adhered to the Mental Capacity Act.
Must Do
Salford Royal Hospital
The trust should ensure that leaders communicate the vision and strategy to all staff.
Should Do
Salford Royal Hospital
The trust should ensure staff understand relevant strategies and can comment and contribute where appropriate.
Should Do
Salford Royal Hospital
The service must ensure that all staff are using the most up to date version of the intranet policy store.
Must Do
Salford Royal Hospital
The trust must ensure that all staff are using the most up to date version of the intranet policy store.
Must Do
Salford Royal Hospital
The service must ensure that staff comply with all aspects of the surgical safety checklist.
Must Do
Royal Victoria Infirmary
The service should ensure the guidance within their PPH policy is clear about defining and grading maternal blood loss in accordance with national guidance.
Should Do
Royal Victoria Infirmary
The service must ensure that guidance in policies is up to date and systems and processes are embedded and operated effectively to ensure compliance with the Mental Capacity Act.
Must Do
Royal Victoria Infirmary
The service must ensure there are clearly defined assurance processes, including audits, and that all staff are aware of the required frequency and recording of these.
Must Do
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.
Must Do
Royal Shrewsbury Hospital
The trust should consider how it communicates the emergency department is a bare below the elbow environment to internal visitors to the department.
Should Do
Royal Hallamshire Hospital
The trust must ensure it implements effective systems to ensure staff adhere to trust policy in relation to the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
Royal Hallamshire Hospital
The service must ensure that staff complete mental capacity and best interest decisions, and they must clearly document the assessment and decision making-making process.
Must Do
Royal Hallamshire Hospital
The trust must ensure it implements effective systems to ensure staff adhere to trust policy in relation to the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
Royal Hallamshire Hospital
The trust must ensure it implements effective systems to ensure staff adhere to trust policy in relation to the use of restrictive interventions including restraint and rapid tranquilisation.
Must Do
Royal Hallamshire Hospital
The trust must ensure staff adhere to the requirement of the Mental Capacity Act.
Must Do
Royal Cornwall Hospital
The serviceshouldensurecleardocumentationandguidanceisavailabletostaffregardingmidwifeexemptionandpatientgroupdirectivemedicine.
Should Do
Royal Cornwall Hospital
The serviceshouldensurestaffareawareofthebabyabductionpolicy,thepolicyisstrengthenedtoincludepreventativemeasures,andthatstaffofalllevelsareinvolvedinlivesimulations.
Should Do
Rotherham General Hospital
The trust should ensure that all guidelines in relation to the administration of time critical medicines are made accessible to staff.
Should Do
Rochdale Infirmary
The service should ensure that all staff use, and wear, required personal protective equipment, including the correct use of surgical facemasks.
Should Do
Rochdale Infirmary
The service should ensure that all staff use, and wear, required personal protective equipment, including the correct use of surgical facemasks.
Should Do
Rochdale Infirmary
The trust should ensure staff understand relevant strategies and can comment and contribute where appropriate.
Should Do
Rochdale Infirmary
The service must ensure that all staff are using the most up to date version of the intranet policy store.
Must Do
Rochdale Infirmary
The trust must ensure that all staff are using the most up to date version of the intranet policy store.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust should ensure they follow their Standard Operating Procedure when placing patients in escalation areas.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure radiology staff use the World Health Organisation checklist before each radiology intervention
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure staff comply with infection control and prevention procedures when looking after patients with or suspected of having an infectious illness
Must Do
HMICFRS recommendations(93)— showing 50 strongest matches
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS’s staff sometimes act in ways that go against its core values. This is leading to bullying in the workplace. Recommendation: The service should ensure that staff act in line with its values and are …
Recommendation
FRS 2021-22 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve how staff understand and display its expected values and behaviours. Recommendation: By 31 August 2022, the service should develop an action plan to ensure that staff …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service isn’t taking a proportionate approach to promoting equality, diversity and inclusion (EDI) in the workplace. Recommendation: By 31 August 2021, the service should make sure that senior leaders respond appropriately and quickly to EDI feedback …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since our last inspection to improve equality, diversity and inclusion. Recommendation: The service should improve equality, diversity and inclusion (EDI) by: • making improvements to the way it collects equality data …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • make improvements to the way it collects equality data to …
Recommendation
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Since our last inspection, the service has made enough improvement to address two of our previous recommendations. But it still needs to improve equality, diversity and inclusion. The following recommendations remain in place. Recommendation: Within 28 days, …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve its EDI. Recommendation: By 30 September 2021, the service should improve how it works with its staff and provides feedback in relation to EDI issues.
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
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: • …
Recommendation
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: • …
Recommendation
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: • …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to make sure …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to improve how …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to establish effective …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: There is a clear intent from senior officers to improve the culture of the service, and many staff reported improvements under the new chief fire officer. However, more needs to be done. We are concerned to have …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: There is a clear intent from senior officers to improve the culture of the service, and many staff reported improvements under the new chief fire officer. However, more needs to be done. We are concerned to have …
Recommendation
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures …
Recommendation
FRS 2023-25 CoC Recommendations: Dorset and Wiltshire Fire and Rescue Service
Cause of concern: The service needs to do more to ensure that its staff routinely demonstrate behaviours in line with its values. We found strong evidence of behaviours that weren’t in line with service values. We were told about cultures …
Recommendation
FRS 2018-19 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: We acknowledge Avon FRS has recently carried out a cultural review and has a plan in place to improve its organisational culture. But it should act immediately to change staff behaviours. It should also make sure all …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn’t engage with or seek feedback from staff to understand their needs. We found this to especially be the case with some under-represented groups. When staff raise issues and concerns, the service doesn’t respond …
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS’s staff sometimes act in ways that go against its core values. This is leading to bullying in the workplace. Recommendation: The service should clearly and effectively communicate its core values to staff. This should …
Recommendation
FRS 2021-22 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve how staff understand and display its expected values and behaviours. Recommendation: By 31 August 2022 the service should provide an updated action plan to:- improve how …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2023-25 CoC Recommendations: Suffolk Fire and Rescue Service
Cause of concern: Senior leaders aren’t managing effectively; they are providing poor scrutiny and oversight and are disengaged from the issues raised by managers and the wider workforce. There is a lack of strategic focus on key people areas. We …
Recommendation
FRS 2021-22 CoC Recommendations: Northumberland Fire and Rescue Service
Cause of concern: The management of dual contracts, for staff working on-call and wholetime in the service, must be improved. Recommendation: By 31 March 2022, the service should:- make sure staff take appropriate breaks between on-call and wholetime commitments for …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • support staff and managers to confidently challenge and manage inappropriate …
Recommendation
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2021-22 CoC Recommendations: London Fire Brigade
Cause of concern: The brigade has shown a clear intent to improve the culture of the brigade, with some staff reporting improvements under the new commissioner. However, more needs to be done. We found evidence of behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Since our last inspection, the service has made enough improvement to address two of our previous recommendations. But it still needs to improve equality, diversity and inclusion. The following recommendations remain in place. Recommendation: Within 28 days, …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve its EDI. Recommendation: By 30 September 2021, the service should give greater priority to how it increases awareness of EDI across the organisation.
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Isle of Wight Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
FRS 2018-19 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: GRFS values are tarnished and are not credible with staff. The service needs to introduce its new values and service structure to allow staff and managers to understand the priorities for the future. Recommendation: The service should …
Recommendation
ICIBI immigration recommendations(1)
PPO death in custody recommendations(23)
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of their responsibilities under the food refusal policy, including sharing information with prison staff and completing an incident report.
The Governor
The Governor should ensure that all managers follow the national instructions for dealing with a death in custody or serious incident, including that all staff directly involved in an incident complete Incident Report Forms as soon as possible.
The Governor
The Governor should ensure that the staff named in this report are given the opportunity to read this initial report in line with paragraph 1.11 of PSI 58/2010.
The Director
The Director should ensure that when a cell door is unlocked, staff satisfy themselves of the safety of the prisoner by obtaining a response in line with local instructions.
The Governor
The Governor should ensure that staff understand local policy around covered observation panels, that prisoners are appropriately challenged, and blockages removed, and that there is not a culture in which prisoners routinely cover observation panels.
The Director of HMP Peterborough
The Director of HMP Peterborough should identify an effective means to ensure all staff understand their responsibilities to check the welfare of prisoners when unlocking cells.
The Director General of Operations of HM Prisons and Probation …
The Director General of Operations of HM Prisons and Probation Service should remind staff of the requirement to adhere to the Civil Service Code and for sensitive and responsible use of social media.
The Head of Healthcare
The Head of Healthcare should ensure that clinical checks on prisoners who are refusing food and/or fluids are carried out and recorded appropriately to ensure risks are managed.
The Governor
The Governor should implement a process for monitoring food collection, to ensure follow up action can be taken where necessary.
The Governor
The Governor should remind staff to switch on their body-worn cameras during reportable incidents and ensure that control room operators prompt staff to do so during an incident.
The Governor of HMP Sudbury
The Governor should ensure that all ROTL board reviews and decisions are made in or following a discussion or meeting between the board members and any other relevant individuals;
The Governor
The Governor should review staff compliance with local roll check procedures and identify any improvements to practice required.
The Governor
The Governor should ensure that staff operate their body-worn video cameras in line with national guidance.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • All necessary paperwork explaining the decision to segregate is appropriately completed, stored, and made available in the event of a PPO investigation.
The Director
The Director should share this report with PCO A and PCO B and ensure that a senior manager discusses the Ombudsman’s findings with them.
The Governor of HMP Birmingham
The Governor should introduce a robust quality assurance process to ensure that staff conduct routine roll checks and welfare checks in line with local and national guidelines.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should all remind staff that it is not appropriate to request or expect prisoners to collect medical equipment in medical emergencies.
The Governor
The Governor should ensure that any decision to move a prisoner while they are attending court is authorised by a wing manager, with the reasons for any move recorded in the prisoner’s records.
The Governor
The Governor should ensure that staff offer reasonable funeral expenses, in addition to repatriation costs, if a deceased foreign national prisoner is repatriated.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff follow local and national instructions regarding body scanners including that body scans are recorded appropriately, and decisions taken following scans are in adherence to the policy and clearly recorded.
The Governor
The Governor should ensure that all staff understand and follow the safeguarding policy, particularly with regard to the division of responsibilities for action to be taken.
The Governor of Holme House
The Governor of Holme House should remind all staff of the importance of completing information reports (IRs) when they receive information about threats of violence and bullying.
The Governor
The Governor should investigate the circumstances that led to Mr Stewart being sacked from his job to establish whether standard protocol was followed.
IOPC learning recommendations(48)
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 …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police should remind custody officers and medical professionals that its guidance warns against medicating those withdrawing from opiates for six hours after arrival in custody due to any doubt as to what they have …
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 …
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 …
Recommendation - Police Federation of England and Wales
The IOPC recommends that the Police Federation of England and Wales should take steps to remind their Federation Representatives to adhere to the College of Policing’s Authorised Professional Practice (APP) guidance and the IOPC’s ‘Statutory guidance to the police force …
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 …
Recommendation - Greater Manchester Police, February 2026
The IOPC recommends that Greater Manchester Police (GMP) should take steps to ensure that accounts given during Post Incident Procedures (PIP) are given in accordance with the College of Policing’s Authorised Professional Practice (APP) guidance and the IOPC’s ‘Statutory guidance …
Police response to an abandoned emergency call – Cleveland Police, March 2020
The IOPC recommends that Cleveland Police take steps to ensure all current and future officers and staff that work in the control room receive sufficient training, in order to perform their roles effectively. Refresher training should be provided as necessary, …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should review current guidance and policy in relation to acting up to ensure there is transparency and clarity on how acting up positions are decided. The guidance should ensure that decisions for officers acting …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that when investigating domestic violence Northumbria Police should use the investigative allocation framework (IAF) using the four point assessment on severity, complexity, solvability and vulnerability and that all decision rationale is clearly documented. This follows an IOPC …
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 should remind all investigative staff to pursue all lines of enquiry and that officers attending incidents document all intelligence received and upload it to policing intelligence systems. And that they are fully aware of …
Teenager took his own life after calling police for assistance – Kent …
The IOPC recommends that Kent Police should ensure that where computer systems are upgraded and updated, that default settings are checked and the operators of those systems are made aware of the changes to settings before use. This follows an …
Teenager took his own life after calling police for assistance – Kent …
The IOPC recommends that Kent Police provide clarity within their policies and guidance in relation to the grading of and dispatch to incidents where a ‘threat to life’ has been received by the control room, but no exact location is …
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 …
Recommendations - South Wales Police, July 2022
The IOPC recommends the NPCC (as holders of the national portfolio for custody and detention) provide guidance to all police forces highlighting: The Prisoner Escort Custody Service (PECS) is a stand-alone system which does not interface with any police systems. …
Recommendations - South Wales Police, July 2022
The IOPC recommends that South Wales Police provide training to custody and detention officers regarding the Prisoner Escort and Custody System (PECS) and the completion of digital Person Escort Record (d PER) forms. Any such training should highlight that: PECS …
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 …
Failure to investigate indecent exposure – Metropolitan Police Service, February 2021
The IOPC recommends that the Metropolitan Police Service (MPS) issues an accessible guidance document to Emergency Response Team (ERT) Officers outlining the expectations and processes involved when handing a case over to the My Investigation Support Team (MIST). This should …
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 …
Recommendations - Hampshire Police, June 2023
The IOPC recommends that the Hampshire & IOW Constabulary develop clear guidance concerning the seizure of animals and the investigation of offences under the Animal Welfare Act 2006. This guidance should: (a) identify whether this is a matter that should …
Man injured during restraint and arrest - Thames Valley Police, March 2018
National recommendation The College of Policing should review the guidance on head injuries in Authorised Professional Practice (APP) to: - provide greater clarity on what constitutes a head injury, including the difference between a traumatic brain injury, other serious injury …
Man found dead after being reported missing - Thames Valley Police, April …
Thames Valley Police’s (TVP) custody records contain a question asking detainees “If you are suffering from mental health problems, depression or considered mentally vulnerable we must put specific support in place. Do you need this support? If yes, give details”. …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police reminds police officers that where the arresting officer does not transport the detainee to custody, information they may have about the detainee is also transferred by some other means and passed on to …
Recommendations - Thames Valley Police, May 2025
The IOPC recommends that Thames Valley Police (TVP) takes steps to ensure that frontline officers understand, and are confident in applying, guidance on method of entry. As part of this, the force should make clear the expectations on officers who …
Recommendations - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police should amend missing persons policy to expand on Chapter 9 “Concern for Welfare or Safe and Well” and the missing persons flow chart. This follows an IOPC investigation where the incident type was …
Recommendations - Nottinghamshire Police, February 2026
The IOPC recommends that Nottinghamshire Police should review and amend policy documents ‘PS260 – Suicide Prevention and Risk Management of Suspects’ and ‘PD485 – Dealing with Indecent Images of Children and Extreme pornography’ to include suspects who are under investigation …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should ensure that when investigating domestic violence incident they undertake a holistic approach rather than dealing with incidents in isolation, in order to proactively identify any previous intelligence, domestic violence history, bail conditions for …
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 …
Recommendation - Metropolitan Police Service, June 2021
The IOPC recommends that the Metropolitan Police Service (MPS) should ensure that expiration dates of protective orders; including restraining and non-molestation orders are flagged and accessible to officers attending domestic violence incidents to enable consideration of this key information into …
Teenager took his own life after calling police for assistance – Kent …
The IOPC recommends that Kent Police should add 'consider sending the concern for safety text message’ if one has not be sent by the call taker' to the list of 'dispatcher actions ' on the PAGES guidance 'Concern'. If a …
Teenager took his own life after calling police for assistance – Kent …
The IOPC recommends that Kent Police should add 'consider sending the suicide text' to the list of actions for the dispatcher on the PAGES guidance 'Suicide - Threats or Attempts to commit'. The suicide text is a text message which …
Recommendations - Hampshire Police, June 2023
The IOPC recommends that Hampshire & IOW Constabulary re-visit the procedures currently in place for the regular review of the retention of animals held by the force, to ensure their retention is still justified. This should include consideration of whether …
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police reminds police officers who bring members of the public into custody, custody sergeants and healthcare professionals to be proactive when conducting a risk assessment for a detainee, by reviewing items that belong to …
Recommendations - Metropolitan Police Service, January 2026
The IOPC recommends that the Metropolitan Police Service (MPS) reviews and updates its call handling policy to ensure its policy complies with the National Standards for Incident Recording (NSIR). This recommendation has arisen as a result of a review of …
Recommendation - Metropolitan Police Service, February 2026
The IOPC recommends that the Metropolitan Police Service (MPS) review its training on officers’ participation in WhatsApp group chats and the requirement to report unacceptable behaviour and/or language through the appropriate channels. This review should consider whether training is sufficiently …
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that the Police Staff Council strengthen the Standards of Professional Behaviour (September 2008) in respect of ‘Authority, Respect and Courtesy’ to make it explicit to police staff that they should not establish or pursue an improper sexual …
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that GMP ensure that officers and staff working with children in any capacity are aware of the appropriate communications channels and that contact with a child via social media is never appropriate. This follows an IOPC investigation …
Recommendations - Greater Manchester Police, December 2020
The IOPC recommends that GMP update their policies on the use of personal social media to reinforce to officers and staff that using personal social media to contact members of the public they have met through their work or duties …
Recommendations - Northumbria Police, March 2021
The IOPC recommends that Northumbria Police take steps to ensure all officers and the wider organisation conform to the expectations of their behaviour under section 26 of the Equality Act 2010, whilst on and off duty, and promote a safe …
Recommendations - Northumbria Police, March 2021
The IOPC recommends that Northumbria Police take steps to ensure all officers and staff are complying with the Association of Chief Police Officers’ Guidelines on the Safe use of the Internet and Social Media by Police Officers and Police Staff …
Recommendations - Northumbria Police, March 2021
The IOPC recommends that Northumbria Police take steps to ensure all officers and the wider organisation conform to the expectations of their behaviour under the Code of Ethics, whilst on and off duty, and promote a safe and open culture, …
Recommendation - Essex Police, March 2021
The IOPC recommends that Essex Police take steps to ensure that supervising officers and staff in community policing departments are made aware of policies around the use of police cadets in community policing, including considerations around safeguarding, and are updated …
Recommendations - North Wales Police, January 2025
The IOPC recommends that North Wales Police review, and where necessary amend, their practice, guidance and policies surrounding the managing and recording of employees’ disabilities and provision of reasonable adjustments for disabled employees. This learning recommendation has arisen following an …
Recommendations - West Yorkshire Police, February 2021
The IOPC recommends that West Yorkshire Police (WYP) takes steps to review its use of the Central Logging of Intelligence Operations (CLIO) in Armed Policing Operations ensuring that command decisions are recorded by all relevant officers in compliance with national …
Recommendation - Metropolitan Police, February 2021
The IOPC recommends that the Metropolitan Police Service formally reviews their internal processes to provide for appropriate monitoring of outstanding calls and that sufficient controls are in place to ensure that policies and procedures are followed, and then takes any …
Investigation into police response to a call from a woman reporting assault …
The IOPC recommends that Cumbria Constabulary should clarify the process for when victims and witnesses should be provided with an information leaflet following a statement being taken, and how this should be recorded. This follows an IOPC investigation where Cumbria …
Recommendation - Surrey Police, April 2022
The IOPC recommends that Surrey Police updates relevant force policies relating to complaint handling [and body worn video (BWV) if appropriate] to include searching for BWV footage relevant to a complaint received and marking it as evidential as part of …
NAO audit recommendations(2)
Bank of England: Managing legal, ethical and staff compliance risks
The Bank should review whether there are material differences in awareness, understanding and perception of risk and compliance between different groups of staff ? for example, based on role, seniority or length of service ? in order to identify ways …
Accepted
The BBC’s implementation of Across the UK
e set out a revised communications and engagement strategy. Building on its learning from phase one, the BBC should set out plans for sustaining culture change from ATUK. As it moves into phases two and three, it needs to collect …
Accepted
IMB annual reports(12)
Brinsford (2025)
HMP/YOI Brinsford, a YOI and Category C resettlement prison, held an average of 545 prisoners during the reporting year. While the environment is generally considered safe and healthcare provision good, the Board has significant concerns regarding the persistent delays in mental health transfers, the poor condition of the estate, and inadequate education and purposeful activity. Key worker compliance is low due to staffing issues, and violence between prisoners increased to 528 incidents.
PRISON
Key concerns
Brixton (2025)
HMP Brixton operated as an overcrowded Category C resettlement prison during the reporting year, with a population of 697 against a CNA of 530. The year was marked by preparations for a delayed re-role to Category B, which disrupted rehabilitation efforts. Positive developments included a reduction in self-harm, improved induction processes, and good staff-prisoner relations, alongside high-quality food provision. However, significant concerns persisted regarding drug availability, property loss, unlawful detentions, and the impact of the re-role on resettlement and purposeful activity.
PRISON
Key concerns
Chelmsford (2025)
HMP Chelmsford, a Category B local prison, reported three deaths in custody and a 4% reduction in self-harm incidents, though the total of 848 remains high. Operational capacity was 660, with 71% of the population being unsentenced, and overcrowding remains a significant concern, especially in the older Victorian wings. The prison saw a decrease in prisoner-on-staff violence but an increase in prisoner-on-prisoner violence and consistently high use of force incidents. Challenges persist with mental health provision due to a lack of specialist beds, property safeguarding, and staff conduct, while the Launchpad platform and improved dentistry services were positive developments.
PRISON
Key concerns
Wayland (2025)
The Wayland IMB's 2025 prisoner attitudes survey reveals a concerning decline in prisoner safety and trust, alongside persistent issues with basic decency standards in accommodation. While some improvements were noted in literacy support and property reception, significant challenges remain in staff-prisoner relationships, access to healthcare appointments, and the overall restrictiveness of the regime. The report highlights high levels of loneliness and a substantial drop in family visits, urging management to address these core concerns to improve prisoner welfare and prepare them for release.
PRISON
Key concerns
Brinsford (2021)
Despite a severely restricted Covid-19 regime, HMP/YOI Brinsford is deemed a safe prison where prisoners are treated fairly. While incidents of violence, self-harm, and substance misuse have reduced due to lockdown, persistent issues include delays in transferring prisoners with mental health needs and an education contract that largely failed to meet prisoner requirements for much of the reporting period.
PRISON
Key concerns
Thorn Cross (2022)
HMP/YOI Thorn Cross experienced a challenging year due to the pandemic and staffing issues but maintained a safe and humane environment. The Board found the prison's rehabilitative culture and healthcare provision to be strong, with positive staff-prisoner relationships. Key concerns include budget pressures, delays in high-risk transfers, persistent property issues, and the need to improve data collection on protected characteristics and reduce absconds.
PRISON
Key concerns
Swinfen Hall (2022)
HMP/YOI Swinfen Hall, a YOI and Category C training prison, held 583 prisoners during the reporting year. The Board noted positive progress in safety initiatives and equality, diversity, and inclusion. However, significant concerns remain regarding slow responses to prisoner property and complaints, insufficient purposeful activity places, and delays in offender management. Healthcare provision, particularly night cover and mental health staffing, also raises concerns.
PRISON
Key concerns
The Verne (2025)
HMP The Verne is a Category C training prison for men convicted of sexual offences, housing 645 prisoners at the end of the reporting period. The Board found it generally safe and humane, commending healthcare, key worker improvements, and the new Building Choices program. Key concerns include staffing uncertainty, lack of 24-hour clinical cover, and the impact of budget cuts on education and purposeful activity.
PRISON
Key concerns
Ford (2025)
HMP Ford, a Category D open prison, continues its focus on rehabilitation and resettlement amidst significant challenges. The prison has seen a rise in high-risk prisoners and increased population churn, while facing persistent issues with failing infrastructure and substantial cuts to the education and training budget. Despite these hurdles, the IMB commends the prison for its generally safe environment, excellent healthcare provision, and ensuring all released prisoners secure accommodation.
PRISON
Key concerns
Hatfield (2025)
HMP Hatfield, a Category D open men's prison and YOI, maintains a generally safe environment with no self-harm, assaults, deaths, or use of force incidents reported in the year. The IMB commends the prison's strong focus on resettlement, evidenced by high rates of employment (62.85%) and accommodation (99.75%) upon release. While facilities are improving through capital maintenance and healthcare provision is well-managed, concerns remain regarding the negative impact of prison population pressures on the Category D ethos, maintenance issues at the Lakes site, and the suitability assessment process for new prisoners.
PRISON
Key concerns
East Sutton Park (2025)
HMP/YOI East Sutton Park is an open female prison praised for its safety, healthcare, and resettlement efforts, with no deaths in custody during the reporting period. Key concerns include ongoing issues with property transfers, inconsistent responses to bullying, and delays in ROTL progression. The Board also highlights accessibility challenges in the old building and spatial constraints in healthcare facilities.
PRISON
Key concerns
Usk and Prescoed (2025)
HMP Usk and Prescoed are generally well-managed establishments with strong leadership, where prisoners report feeling safe and experience positive staff relations. However, the Board raises significant concerns regarding the welfare and progression of specific prisoner groups, particularly IPP prisoners, and elderly/disabled individuals requiring social care. Challenges related to staffing, the impact of early release schemes on rehabilitation, and delays in Release on Temporary Licence (ROTL) are highlighted as key areas needing intervention from both the Minister and HMPPS.
PRISON
Key concerns
IMB individual recommendations(233)— showing 50 strongest matches
Berwyn (2020)
There is a need to ensure that systems and policies are consistent and fully understood both by prisoners and staff.
Governor / Director
Durham (2024)
How will you ensure that staff fully understand the eligibility and process for clothing parcels to be handed in/delivered to the prison so that consistent guidance is given to prisoners?
Governor / Director
Portland (2022)
What efforts will the Governor make to ensure that all staff comply with the new regulations concerning the wearing of BWC?
Governor / Director
Norwich (2022)
The Board asks the Governor to provide information on plans for making sure that all communications especially Governor's notices to prisoners (GNTPs) are distributed to, seen and understood by all prisoners including those who do not read/speak English This concern was highlighted in the 2020-21 annual report but the Board does not see any improvement.
Governor / Director
Downview (2023)
A lack of consistency in the application of prison rules by staff is frequently mentioned by prisoners during our monitoring. This may be exacerbated by staff inexperience and the ongoing regular staff redeployment. Staff tell us they feel undermined and less confident in maintaining safety, and prisoners cite frustration at perceived unfairness when senior managers overrule decision-making (sections 5.3, 5.6).
Governor / Director
Lancaster Farms (2025)
What steps will the Governor take to ensure that all prison officers wear and switch on their body worn video cameras?
Governor / Director
Five Wells (2025)
When will the policy be enforced on the use of vapes for both staff and prisoners?
Governor / Director
Five Wells (2025)
When will the policy be enforced on the use of vapes for both staff and prisoners?
Governor / Director
Lancaster Farms (2022)
To ensure that processes previously agreed with the Board, such as that the Board will be notified immediately following the deployment of PAVA, deaths in custody and/or the use of the special cell, are implemented. In addition, to ensure that the appointment to the vacant position of Board clerk is prioritised, with a clear remit for that person to support …
Governor / Director
Low Newton (2020)
Can the equality and diversity policy be displayed on all wings and also in areas where there is a high volume of resident activity?
Governor / Director
High Down (2020)
What actions does the governor intend to take to ensure that welfare checks are done in a timely manner and are adequately recorded?
Governor / Director
Ford (2020)
For the second year running the Board comments on your service’s apparent lack of understanding of Category D open prisons. The Prisons National Framework response to COVID-19 including the coloured Levels/Stages diagram and supporting text failed to mention ROTL, even at Levels 1 or 2 where it might be expected. The Board understands that the number one priority was the …
HMPPS
In Progress
Exeter (2020)
Will the Governor undertake to improve staff “buy in” and commitment to CSIP and monitor compliance and case management? (See paragraph 4.4).
Governor / Director
In Progress
Charter Flight (2020)
The escorts must be instructed to explain the contents of the individual information packs to all returnees, with assistance, where needed, from interpreters (see paragraph 4.3.5).
Other
Charter Flight (2020)
Continued use of restraint and the reasons for this were rarely noted in the PER, despite the routine instruction to escorts during the staff muster to record (paragraph 3.8.8). This should be standard practice.
Other
Hewell (2021)
Maintain culture change pressure to have a consistent standard of staff behaviour towards prisoners.
Governor / Director
Gartree (2021)
Will the Governor ensure that all custodial managers are aware of the occasion when the Board needs to be notified of incidents, deaths in custody, use of force and all other routine notifications which are outlined in the memorandum of understanding between HMPPS and the Management Board for the IMB, dated December 2019?
Governor / Director
Wakefield (2022)
Key workers – there is some evidence of staff referring prisoners to the IMB rather than dealing with matters themselves. Keywork provides an opportunity for staff to engage with prisoners and resolve issues without the need to access the IMB. Our data (see ‘the work of the Board’) suggests that the present level of applications received by the board is …
Governor / Director
Oakwood (2022)
The Board continues to be concerned about prisoners in the servery not wearing the appropriate personal protective equipment (PPE) and clothing. Notwithstanding that Aramark provided continuity of a balanced menu and two cooked meals a day, the Board is still concerned about the quality, quantity and variety of the food provided and the ensuing waste that results, and that the …
Governor / Director
Isis (2022)
Having published a Prisoners’ Property Policy Framework, ensure that it is fully implemented and adhered to.
HMPPS
Swaleside (2023)
Facilities for female officers are inadequate and it is not acceptable that they have to share locker rooms with male staff. This needs to be addressed, especially as there are now many female officers working in the prison.
Governor / Director
Oakwood (2023)
Can the Director take steps to address the standard of hygiene on the serveries? Issues of dirty or incomplete Personal Protective Equipment (PPE) are regularly reported on the Board’s Rota Report, as are concerns about missing or broken equipment. Repairs to broken kitchen equipment are often prolonged.
Governor / Director
Foston Hall (2023)
Staffing issues have had an impact on the implementation of key working, as intended in the offender management in custody (OMiC) model. What action will you be taking to improve staff availability?
Governor / Director
Bronzefield (2023)
How does the prison plan to ensure that complaints are handled in line with the Prisoner Complaints Policy Framework?
Governor / Director
Norwich (2024)
There would still appear to be a problem with the circulation and comprehension of communications released to prisoners, especially Governor’s notices to prisoners (GNTP). Of the prisoners who responded to the IMB’s 2023-2024 questionnaire, only 33% found them easy to access and only 48% understood their content. What steps could be taken to improve the situation?
Governor / Director
London STHF (2024)
During inductions, detained people should be reminded that they have the right not to disclose certain information, such as marital status and religion in line with Rule 21 of STHF rules.
Other
Feltham (2024)
Will you ensure that the shortfall between planned hours of education and delivered hours continues to be monitored and reduced?
Governor / Director
Feltham (2024)
What further steps will be taken to reduce staff absence, particularly during school holiday periods?
Governor / Director
Bristol (2024)
Key working is focused on the high-risk cohorts of prisoners. Will key working be available for all prisoners in the coming year?
Governor / Director
Thorn Cross (2025)
What plans are there to ensure there are adequate numbers of skilled cleaners? (5.1.4)
Governor / Director
Rochester (2025)
The Board understands and supports the reasoning for the re-rolling of the top site at Rochester as a prison for PCoSos, but it was rushed through and creates significant logistical issues for the prison, which will take time to bed down. The Board believes a period of stability is required, without further changes to leadership and functions.
HMPPS
In Progress
Portland (2025)
The Governor should undertake steps to ensure that key work continues to increase so all prisoners benefit on a regular basis.
Governor / Director
Lancaster Farms (2025)
When will the Governor increase the effective use of key working at the prison, with demonstrable targets and outcomes?
Governor / Director
Erlestoke (2025)
What can be done to reduce the pressure on the Offender Management Unit (OMU), enabling offender managers to manage more consistently their caseload, particularly given the likelihood of further changes to sentence and release criteria?
Governor / Director
East Sutton Park (2025)
Could the Prison Service implement an effective system for managing prisoners’ property and transfers? The ESP Board notes that a related key performance indicator (KPI) once existed but was discontinued. Could this KPI be reinstated?
HMPPS
Partially Accepted
Durham (2025)
How will you ensure that staff fully understand the eligibility and process for clothing parcels to be handed in/delivered to the prison so that consistent guidance is given to prisoners? (5.8.4)
Governor / Director
Doncaster (2025)
Internal property issues remain a concern for the Board and cause great frustration for prisoners. Will the Director commit to making the resolution of this issue a top priority in the coming year?
Governor / Director
In Progress
Cardiff IMB (2025)
Sut bydd y trafodaethau hyn yn cael eu datrys ddechrau 2026 i gefnogi system gweithwyr allweddol gwell yng Ngharchar Caerdydd.
Governor / Director
Cardiff (2025)
The Board acknowledges the attempts made to introduce a revised staffing profile during the reporting period. How will these negotiations be resolved early in 2026 to support an improved key worker system in HMP Cardiff.
Governor / Director
Birmingham (2025)
What will the governor do to resolve the ongoing issue relating to shortages of kit?
Governor / Director
Noted
Berwyn (2025)
We are still receiving reports from prisoners saying that they do not know who their key worker is.
Governor / Director
Wealstun (2020)
Ensure that all relevant paperwork and witnesses are available for all adjudications, especially for those to be heard by the independent adjudicator (see paragraph 5.2.14).
Governor / Director
Swinfen Hall (2020)
The key worker programme has been inadequately implemented, averaging only 52% of expected contact time (see paragraph 5.3(b)). Similarly, the key worker clothing parcels initiative was poorly executed (although hugely welcomed by prisoners) and plagued by administrative difficulties (see paragraph 5.3(c)]. How will these programmes deliver expectation in a self-regulating and sustained way?
Governor / Director
Pentonville (2020)
Will the recording and scrutiny of use of force incidents be prioritised?
Governor / Director
Norwich (2020)
What plans does the Prison Service have to rationalise and streamline reporting information and assurance? Mandatory paperwork is excessive for staff and the SMT, cutting down their time for hands-on management and interaction with prisoners.
HMPPS
In Progress
Oakwood (2020)
Following concerns expressed in last year’s AR, the Director should consider again, how to ensure that staff enforce the use of Personal Protective Equipment (PPE) across all houseblocks and ensure the regular availability of appropriate cleaning materials so that the serveries are maintained to a more consistent standard of hygiene and cleanliness.
Governor / Director
North Sea Camp (2020)
Ensure that any future wages changes are fully understood by all residents before implementation.
Governor / Director
Isis (2020)
deliver the ‘prisoners’ property policy framework’ that the minister stated in response to previous annual reports that HMPPS was planning to publish (see section 5.8)
HMPPS
In Progress
Foston Hall (2020)
The variable operation of the personal officer scheme (see paragraph 5.3.3).
Governor / Director
Noted
Foston Hall (2020)
The induction pack is out-of-date and is not provided in other languages. (see paragraph 4.1.1).
Governor / Director
Noted
Health investigations(850)
*Mental health homicide investigation legacy report into the care and … — Rec L6
The trust should monitor and review the newly-developed personality disorder initiatives to ensure that all staff, medical and otherwise, are aware of what personality disorder services are available, how to refer, and the waiting time for referral. This should include knowledge of the referral process and criteria for referring service …
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L3
The trust should ensure that all staff adhere to the trust’s policy and procedure for managing formal and informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 15
Trusts and social services should ensure that there are policies on, and staff training in, the subject of appropriate disclosure of confidential information.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 4
The trusts should issue a policy statement in regard to the role of forensic CPNs in generic teams.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
Trusts should ensure that there are policies on, and staff training in, the subject of appropriate disclosure of confidential information.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 5
The Home Office should take urgent action to ensure that current supervisors have a clear understanding of the grounds for recall. Furthermore, the Home Office should establish a system of informing supervisors of changes in the law relating to conditionally discharged patients, and of the implications.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
There is a confusion in Guidelines for Psychiatric Supervisors in the use of the terms ‘consultant’ and ‘supervising psychiatrist’. These should be clarified, particularly with regard to specialist registrars.
south_east
An independent investigation into the care and treatment of a … — Rec Recommendation 4
The Trust should ensure that all Early Intervention in Psychosis staff are aware of and actively implement procedures outlined in the Early Intervention in Psychosis Operational Policy.
south_east
An independent investigation into the care and treatment of a … — Rec R2
All Early Intervention in Psychosis staff to be aware of and actively implement procedures outlined in the Early Intervention in Psychosis Operational Policy following its launch in March 2019.
south_east
Independent investigation report into the care and treatment of Yusuf — Rec 4
Staff were unaware of the website resource Healthier Together which contains information leaflets and advice (for safety netting). • Parents should be directed to the Healthier Together website for written patient information. • Nursing and medical staff working in the paediatric UECC should be aware of this resource. Leaflets should …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 3
The administration of oxygen was not in line with national guidance although there was evidence that the amount given did have a positive effect on the patient’s condition. For children who have been assessed as hypoxic, oxygen must be administered in line with JRCALC guidelines.
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 5
Staff were unaware of the website resource Healthier Together which contains information leaflets and advice (for safety netting). • Parents should be directed to the Healthier Together website for written patient information. • Nursing and medical staff working in primary care should be aware of this resource. Leaflets should be …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Stefan Welch, Brighton (2010) — Rec 7
The Trust must revise all policy documentation in keeping with the findings of this Investigation report and as set out in the recommendations above. All policy documentation should be subject to review and audit for both compliance and effectiveness as part of the Trust audit cycle.
south_east
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec 3
The notes for the Guidance of Social Supervisors should be reviewed and revised to take account of potential conflicts in the roles of social workers arising from changes in the Community Care, Mental Health and Criminal Justice legislation;
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 16
That the Trust take immediate steps to ensure that all staff are made aware of or are reminded of the policies in place with regard to the management of Serious Untoward incidents, and, if and insofar as necessary, this Independent Inquiry report be used as a vehicle for further training …
midlands
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.16
There should be clear guidance to Police Community Support Officers on the procedure to be followed if an arrest under section 136 Mental Health Act 1983 is indicated.
south_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 10
The Trust should take action to raise the profile of issues associated with vulnerable adults and safeguarding. In particular the Trust should ensure that staff are aware of the inter-agency Safeguarding Policy and their obligations under it.
north_west
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 16
There should be an ongoing training programme in relation to the policies in force to ensure that all staff are familiar with the requirements, and appropriate supervision to ensure that there is compliance with such policies.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 27
Trusts should ensure that all policies include the production and review dates; the author; the organisation to whom it relates and are archived in a system, preferably electronic, where easy access is available.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 9
Trusts should review policies and ensure that there are up to date ‘lone worker’ or ‘home visit’ policies in place in each part of the front line services, that staff are aware of such policies, and aware of the procedures in place to implement them.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 1
Trusts should ensure that new CPA guidance is or has been implemented and that this is fully understood by staff and supported with intensive training.
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.i
The Trust’s Supervised Discharge Policy needs to be re-written to better reflect the Department of Health’s Guidance. Staff should receive training on the use of supervised discharge and guardianship.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.d
Senior Managers and staff working on the wards should be made aware of the provisions of Chapter 19 of the Code, which relates to the management of patients presenting particular problems, as a result of their disturbed behaviour. This chapter gives guidance on the response of the clinical team to …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.b
All leave for detained patients must be authorised in accordance with Section 17 of the Act and Chapter 20 of the 1983 Mental Health Act Code of Practice. All leave should be documented on the Trust’s Section 17 Leave Form, which should contain all the information requested on each occasion …
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.v.a
All staff should have regular training on the use of the Act and Code of Practice, including any changes in case law, which may affect their professional practice. Wherever possible, training should be multi-disciplinary and multi-agency.
north_west
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec j.
That it should be a disciplinary matter for a trust or social services employee (including a consultant) to refuse to act as a patient‘s care co-ordinator when required to do so by the local CPA convenor, or without reasonable excuse to fail to attend a CPA meeting arranged by their …
midlands
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 34
DPT will audit understanding of and adherence to operational policies and care pathways.
south_west
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 33
DPT will publish its ratified operational policies on the Trust internet and Clinical Team Leaders will be tasked with ensuring all team members are conversant with the operational policy for their team through induction and supervision.
south_west
Independent investigation: John Stevens, Woking (2001) — Rec 12
We recommend that the North West Surrey Mental Health Partnership Trust develops a training programme to ensure that all staff, particularly junior doctors, are fully aware of their obligations in the use of the Mental Health Act and included in induction, supervision and appraisal arrangements.
south_east
Independent investigation: John Stevens, Woking (2001) — Rec 11
We recommend that the Commissioners, the North West Surrey Mental Health Partnership Trust and Surrey Social Services review and updates the Section 136 policy and reinforces the legal requirement of the ASW to interview the patient.
south_east
Independent investigation: Janet Frost, Meadowfielsd – County Hospital Durham (1999) — Rec 8.8
Management of the trust should ensure that the County Hospital has proper policies and guidance in place on key aspects, including breach of the patient contract, confiscation of alcohol, relationships between patients, contact with families and carers, leave arrangements, risk assessment, professional supervision, and discharge arrangements.
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 12
The Mental Health Trust should provide a locally produced ‘Junior Doctor Handbook’for training schemes, incorporating written policies relevant to junior doctors and including discharge procedure.
london
Independent investigation: Faith Lovemore (6 wks), Cambridge (2009) — Rec 9
The Trust must as a matter of urgency ensure that all staff are aware that, under the remit of the Mental Health Act 1983 (as amended 2007), if there is concern about a service user relapsing they are legitimately able to undertake/refer for an emergency Mental Health Act assessment. The …
east_of_england
Independent investigation: Edna Gadsby, Liverpool (2010) — Rec 7
That the Trust ensures that robust systems are in place to give assurances that all Trust wide policies are implemented and adhered to throughout Mersey Care and that audit arrangements evaluate compliance
north_west
Independent investigation: Denise Eckersley, Leeds (1999) — Rec 5
The Trust should ensure that there is clear guidance for all those involved in the clinical care of patients in the community, as to the formal steps that they should take, if and when something goes wrong. The Trust should ensure that its staff have a clear understanding of its …
north_east_yorkshire
Independent investigation: David Huitson, Newcastle (2001) — Rec 7
That the Newcastle, North Tyneside and Northumberland Mental Health NHS Trust should ensure that its guidance on the role of the care co-ordinator is being followed in relation to communication between professionals.
north_east_yorkshire
Independent investigation: David Huitson, Newcastle (2001) — Rec 6
That the Newcastle, North Tyneside and Northumberland Mental Health NHS Trust should make explicit arrangements for staff to undertake home visits in safety and security with the appropriate policies to support this activity clearly understood.
north_east_yorkshire
Independent investigation into the care and treatment of Mr X — Rec 15
In keeping with Recommendation 13 the Trust should revise its clinical audit tools to ensure they are sensitive enough to detect policy non-compliance. The Trust also utilise training and clinical supervision to reinforce the importance of policy adherence.
X This is the independent investigation report into the care and treatment of Mr X who committed a homicide in 2013. Mr X was in receipt of services from Oxleas NHS Foundation Trust
london
Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006) — Rec 5
The policy framework issued by corporate management to line managers and staff should be followed consistently. It is of particular importance that trusts monitor and ensure, by way of regular audit, compliance with policy on a continuing and enduring basis.
north_east_yorkshire
Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006) — Rec 1
The Panel has found that there was an inconsistent implementation of the care programme approach (CPA) organisational policy at key points in P’s care. Although the Panel do not see the need for organisational review of the local CPA policy, the mental health trust should review its assurance arrangements to …
north_east_yorkshire
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 16
A policy for multi-disciplinary working should be developed and all staff should comply with it. The policy should require that, amongst other things: the roles of the multi-disciplinary team members are defined; records of attendance at ward rounds and discharge planning meetings are kept; key discussion points and any disagreements …
north_west
Independent investigation: Amina Ali, Sheffield (2004) — Rec S4
Amend Appendix three to the Trust’s current CPA policy (see page 83 of this report).
north_east_yorkshire
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 50
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in the Care Programme Approach (CPA) and its associated guidance.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 49
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in the Mental Health Act 1983 and its Code of Practice.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 44
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients are aware of local domestic violence services and referral pathways.
midlands
Independent investigation: Valerie Sexton, Gosport (2000) — Rec 5.4
We recommend that: 1. There is a need to clarify the application of the Joint Operational Policy to consultant psychiatrists. 2. The CPA documentation should be revised to make clear where consultant psychiatrists are not expected to use forms and checklists which have been designed for use by other practitioners …
south_east
Independent investigation: Tracy Anstice, Flitwick (2011) — Rec 8
SEPT and HPFT should review the joint protocol Treatment of staff and their relatives to ensure that it includes all the points included in the recommendation in the multi-health agency investigation.
east_of_england
Independent investigation: Tracy Anstice, Flitwick (2011) — Rec 6
HPFT and SEPT should provide assurance that all staff adhere to children’s and adults’ safeguarding policies and procedures and monitor that these are in routine use.
east_of_england
Independent investigation: Tracy Anstice, Flitwick (2011) — Rec 3
SEPT should ensure that all clinicians put into practice the trust risk assessment and risk management policies and provide assurance that these are in routine use.
east_of_england
Independent investigation: Thomas Abraham, Gloucester (2019) — Rec 1
Clozapine management: Trusts should ensure staff understand the fundamental elements of clozapine management, including service user capacity, consent, risk management and individual responsibilities. This should be underpinned by up-to-date policy, training, and a review of all clozapine patients to ensure their management is undertaken in line with expected practice.
south_west
Scottish Fatal Accident Inquiries(19)
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 prisoners being …
Dec 2005
Angus MacDonald Malone
Oct 2009
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
Mhairi Samantha Convy and Laura Catherine Linda Stewart
However, as the evidence in this Inquiry may raise a question about the level of awareness of the DVLA guidance among medical practitioners I believe the best course in the circumstances is to direct the Sheriff Clerk to bring this Determination to the attention of the appropriate medical bodies - the relevant Royal Colleges - for information, consideration and any …
Nov 2014
Lorna MacDonald
In particular, managers must implement fully the health board’s Lone Working Policy and Policy for Managing Work Related Driving Risks. While that omission does not have any bearing on this inquiry, it could be relevant in future accidents and consideration should be given to ensuring that such sites are preserved in future.
Nov 2014
Alasdair Finlay Macleod
In terms of section 26(1)(b) of the 2016 Act the court recommends that: (a) all fishermen should make themselves aware of and follow the terms of Marine Guidance Note (MGN) 588 (F) which states that “failure to ensure the provision and wearing of PFDs and/or fall restraint harnesses by all fishermen working where there is a risk of falling overboard …
Mar 2019
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 the arrangements …
Dec 2019
Angus McAskill
(i) That the Scottish Prison Service should review and revise standing orders for prison officers so as to secure that, where a prisoner complains of feeling unwell, with chest pains, sweating, and a sore throat, at a time when no medical or nursing staff able to carry out an electrocardiogram are on duty within the prison, the prison officer in …
Jan 2021
James Kelly MacGregor
a) A review of the training of officers should take place in order to ascertain whether specific and sufficient reference to the Standard Operating Procedure is included. Thereafter, consideration should be given to officers being tested as part of their training, potentially by way of open book examination, in order to ascertain whether they are familiar with referencing the Standard …
Apr 2023
Craig Alexander Corbett otherwise Duffy
It seems to me that a similar message, to the effect that one should not go to sea in any command (or even work) situation until one's body is clear of alcohol or at least no longer impaired by it, could and should be more strongly and more continuously disseminated amongst the sea-going community until the message really starts to …
Nov 2005
John MacDonald
It seems to me that a similar message, to the effect that one should not go to sea in any work situation until one's body is clear of alcohol - or at least no longer impaired by it, could and should be more strongly and more continuously disseminated amongst the sea-going community until the message really starts to drive home. …
Nov 2005
Graham Rattray
It seems to me that where risks are identified those responsible for the daily care of the vulnerable adult must ensure that carers know and understand the identified risks, know and understand agreed strategies to minimise those risks and know and understand what to do in the event that the risks in fact manifest themselves.
Jan 2008
Thomas Kilpatrick
There ought also to be proper considered and written guidance for dealing with the morning intercom calls when no response is received. Whether he should have been allocated a place within this complex is another issue and it would be appropriate for very careful consideration, and assessment, to be carried out before such a person is allocated such a tenancy …
Apr 2009
Mary MacMillan Smith Forrest
(1)There should be defined rules or guidelines for nurse co-ordinators and compulsory training for them. (2) All staff nurses or charge nurses who are not acting in the role of nurse co-ordinator should be fully aware of the role of co-ordinators. B514/08 Mary Macmillan Smith Forrest (3) Much more training on procedures including risk assessment, observation and documentation should be …
Dec 2005
Neil William Bremner
Nonetheless, it is clear from the evidence of both Mr Marr and his colleague Mr Radcliffe that the Health and Safety Executive might profitably consider rewording the information sheet so as to achieve the effect suggested by Mr Main and I recommend that they should so consider the matter. They might also wish to consider whether there are any reasonable …
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
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
Brian John Gilfillan
I note that the discipline policy, contained in the management of employee conduct policy document produced by NHS Fife, does not deal with the issue of employee welfare during the whole period of the disciplinary action. This is something which ought to be formally recognised, and addressed.
Feb 2010
Terence Michael Griffin
It does occur to me thought that there was merit in the suggestion that the guidance issued to doctors on this issue might be made more directive. If the guidance was to the effect that a doctor in the situation under discussion here had to advise the patient that he must not drive and that the patient was obliged to …
Sep 2013
Article 2 learning points(3)
— LP 5
Methods of translating Formal Policy Documents into accessible and simplified instructions for Prison Officers using skills-based training methods should be developed.
HMPPS
— LP 19
We recommend that officers’ attendance at ward rounds is embedded as a norm on HMP Pentonville’s Healthcare unit, if this is not already the case. This should help further improve understanding and promote a sense of collegiate working among discipline and clinical staff.
PPG
Accepted
— LP 1
At an organisational and cultural level, we recommend that further measures are taken to close the perceived gap between the main prison and the Healthcare unit at HMP Pentonville. This should help create a greater sense that HMP Pentonville is functioning as one organisation, comprised of staff and managers working …
HMPPS
Accepted
Detention investigations(34)
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)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R37
The age dispute policy should be amended to make explicit that it is the duty of staff members who have any cause to believe that a detainee is under age to report it to a manager or ensure that it has been reported. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R26
G4S managers and the SMT should: • improve the environment in the reception area at Brook House and make it more welcoming; • consider how all new arrivals can be interviewed in privacy; and • agree with the Home Office how they will provide showers for new arrivals. (To be …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R25
Residential DCMs and wing staff should ensure that all detainees have access to cleaning products to clean their rooms, including washbasins and toilets. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R24
Residential DCMs must hold staff to account for ensuring wings are maintained at an acceptable standard cleanliness. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R23
The SMT must resolve the issue of the inadequate cleaning of the wings either by agreeing with that it will undertake the cleaning of wings or by ensuring that wing orderlies keep wings to an acceptable standard of cleanliness throughout the day, that they are properly supervised and allowed access …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R21
The SMT and staff must enforce the ban on smoking inside Brook House. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R30
The SMT and DCMs must ensure continued adherence to the induction policy. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R22
The SMT and residential DCMs must ensure that adequate numbers of staff are on duty throughout the service of meals to ensure orderly queues and service of meals. (To be completed within 3 months)
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 51
I recommend that contract monitors be instructed personally to investigate all allegations against members of staff.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 45
I recommend that clear guidelines are produced for contract monitors.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 34
I recommend that Securicor requires staff to take regular meal-breaks.
Immigration Detention
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)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R39
The SMT, in consultation with the local safeguarding boards, should review and redraft the safeguarding policy to ensure that it: • has a clear and easy-to-follow scheme and does not contain errors in drafting and meaning; • makes clear to staff their principle duties and responsibilities in relation to safeguarding, …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R1
The SMT should be more present in the centre and should consider how they can better engage with staff. (To be completed as a matter of urgency)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 59
IND consults upon the merits of incentives schemes and the terms of a single national framework - to reflect a consistent set of principles and processes - within which schemes could operate.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R46
The SMT and safeguarding team should ensure that all incidents of violence and bullying at Brook House are investigated in a timely way. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R27
G4S should amend its induction policy to make it clear that a detainee posing a risk of any significant violence to others will be justification for accommodating the detainee in a single occupancy room. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R17
The SMT must design and implement as a matter of urgency purposeful and better-resourced education, activities and entertainments programmes. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R4
The SMT at Gatwick IRCs must review arrangements for providing care and support to staff and ensure that they have ready access to a care service they trust. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R51
The SMT and G4S managers should review the policy and arrangements for raising concerns and their own handling of such matters to ensure that they encourage and support staff to report wrongdoing or misconduct or inappropriate behaviour by colleagues and managers. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R48
The safeguarding team should survey staff at Brook House regularly to ascertain their experience of and perspective on violence and bullying and its causes. (To be completed within 6 months)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 41
contract monitors regularly check that the Detention Centre Rules and operating standards are readily available to detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 29
IND issues instructions to Immigration Service staff in removal centres governing effective engagement with detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 27
when a new centre opens, the relevant Project Board issues specific instructions to DEPMU about population build up.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 49
I recommend that a formal protocol is drawn up between the contractor and the Immigration Service setting out the circumstances in which attempts at removal could be abandoned.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 38
I recommend that IND and its contractors jointly review the shift patterns worked by staff in the immigration detention arena.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 35
I recommend that IND and Securicor review the logistics of escorted removals to minimise the time that staff and detainees spend waiting at airports.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 14
I also recommend that a new term be chosen that reflects the positive nature of the arrangements.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R6
Managers should review the centre’s policies, its recruitment, training and appraisal arrangements and the regime at the centre to ensure they are consistent with its mission, role and purpose.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R5
Managers at Yarl’s Wood should put in place a programme of organisational development work involving all staff, to develop a clearer and better shared understanding of the centre’s mission, role and purpose, and the cultures and arrangements, including staffing arrangements, that will ensure the appropriate care of Yarl’s Wood’s residents. …
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 54
IND arranges for the weight of each contract monitor post to be assessed to determine both the appropriate grade of the contract monitor and the level of support he/she should have.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 16
GSL reviews its fire signage at all its centres and carries out regular management checks to ensure all fire safety measures are complied with.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 20
Alongside the contractors, I recommend IND considers establishing a zero-tolerance campaign across the detention estate, with appropriate posters and literature, to remind staff of the expected standards of conduct.
Immigration Detention
Independent reviews(50)
Pickles Electoral Fraud Review — Rec R49
A protocol for reporting within a local authority on issues relating to electoral fraud should be developed and guidance given by the Electoral Commission in conjunction with the National Police Chiefs Council and other relevant bodies.
Other
Pickles Electoral Fraud Review — Rec R9
Clearer guidance should be provided on the circumstances in which Electoral Registration Officers should seek further evidence as to an applicant's address.
Other
Pickles Electoral Fraud Review — Rec R7
Completed postal ballot packs should only be handed in at a polling station by the voter or a family member / designated carer acting on their behalf – a limit of two should be applied for any one person handing in completed ballots and require an explanation as to why …
Other
Pickles Electoral Fraud Review — Rec R5
Guidance and training should be strengthened to ensure that staff in polling stations enforce the rule that voters go to the booth individually.
Other
Kerslake Birmingham Review — Rec 3
Birmingham City Council's governance needs to be reset in the following ways: a. the council needs to clarify roles, responsibilities, behaviours and ways of working expected in relation to the of the Leader, Cabinet, councillors Chief Executive and officers. The strategic, executive, independent scrutiny and community roles of members needs …
Other
Litchfield WCA Review Year 4 — Rec 16
Give greater clarity about the role and parameters of Decision Makers with a particular focus on the meaning of "empowerment".
Employment & Work
Cavendish Review — Rec 15
Skills for Health should refine its proposed code of conduct for staff, and the Department of Health must review the progress of the social care compact: and substitute a formal code of conduct for employers if a majority have not acted upon it by June 2014. Time to Care
Health & Social Care
Dearing Higher Education Review — Rec 47
We recommend that, over the next year, all institutions should: review and update their staff development policies to ensure they address the changing roles of staff; publish their policies and make them readily available for all staff; consider whether to seek the Investors in People award.
Education
Crick Report — Rec 4.10
everyone directly involved in the education of our children – politicians and civil servants; community representatives; faith groups; school inspectors and governors; teacher trainers and teachers themselves; parents and indeed pupils – be given a clear statement of what is meant by citizenship education and their central role in it. …
Education
Laming Review (Baby P) — Rec 23
Every Children's Trust should assure themselves that partners consistently apply the Information Sharing Guidance published by the Department for Children, Schools and Families and Department for Communities and Local Government to protect children.
Other
Gloster Report (LCF/FCA) — Rec 5
the FCA should have appropriate policies in place which clearly state what steps should be taken or considered following repeat breaches by firms of the financial promotion rules.
Other
Gloster Report (LCF/FCA) — Rec 4
the Senior Management of the FCA should ensure that product and business model risks, which are identified in its policy statements and reviews as being current or emerging, and of sufficient seriousness to require ongoing monitoring, are communicated to, and appropriately taken into account by, staff involved in the day-to-day …
Other
Gloster Report (LCF/FCA) — Rec 2
the FCA should ensure that its Contact Centre policies clearly state that call-handlers: (i) should refer allegations of fraud or serious irregularity to the Supervision Division, even when the allegations concern the non-regulated activities of an authorised firm; (ii) should not reassure consumers about the non-regulated activities of a firm …
Other
Nolan Report (1st) — Rec 48
Board members and staff of all executive NDPBs and NHS bodies should be required on appointment to undertake to uphold and abide by the relevant code, and compliance should be a condition of appointment. (para 4.95)
Other
Nolan Report (1st) — Rec 47
It should be mandatory for the board of each executive NDPB and NHS body to adopt a code of conduct for their staff. (para 4.91)
Other
Nolan Report (1st) — Rec 46
The adoption of a code of conduct for board members should be made mandatory for each executive NDPB and NHS body. (para 4.91)
Other
Nolan Report (1st) — Rec 32
A central or local record of invitations and offers of hospitality accepted should be kept in all departments and agencies. There should be clear rules specifying the circumstances in which staff should seek management advice about the advisability of accepting invitations and offers of hospitality. (para 3.72)
Other
Nolan Report (1st) — Rec 28
There should be regular surveys in departments and agencies of the knowledge and understanding staff have of ethical standards which apply to them; where such surveys indicate problem areas, guidance should be reinforced and disseminated appropriately, particularly by way of additional training. (para 3.61)
Other
Nolan Report (1st) — Rec 27
The Cabinet Office should continue to survey and disseminate best practice on maintaining standards of conduct to ensure that basic principles of conduct are being properly observed. (para 3.59)
Other
Selous Review — Rec 108
The Ministry of Defence, in collaboration with the Chain of Command and the Families Federations, to ensure every Serving member of the Armed Forces and every spouse/partner knows about the Covenant and understands how it can benefit them. Armed Forces Covenant: medium term
Other
Selous Review — Rec 102
The Armed Forces to ensure that, as far as is possible, Ministry of Defence Harmony Guidelines and reasons for breaching them are fully understood by military families and that they are adhered to and breached only in unavoidable and exceptional circumstances.
Other
Calvert-Smith SFO Review — Rec 11
The need for adherence to the Operational Handbook by all SFO staff needs to be clearly articulated and communicated to all staff. Within six months of the publication of this Review a communication campaign should be designed to deliver this message, the reasons for its importance and the consequences of …
Justice & Legal
Naylor Review — Rec 6
The NHS Property Board should produce improved guidance on building standards so they support the Five Year Forward View (5YFV) and deliver value for money. This should gather evidence on the most appropriate estate models through the vanguards programme and should prioritise new guidance on primary care facilities.
Health & Social Care
Naylor Review — Rec 5
The NHS Property Board should produce improved guidance on estates planning and disposals for the NHS, covering the scope of estates planning, accessing private sector expertise, models for affordable housing for NHS staff and partnerships with both housing associations and developers.
Health & Social Care
Naylor Review — Rec 4
The NHS Property Board should be the primary voice to the system on estate matters and should work with national bodies to ensure that the system receives clear and consistent messages about the importance of developing a modern fit for purpose estate, releasing land and addressing backlog maintenance.
Health & Social Care
Bailey DBS Review — Rec 2
Consideration be given to amending the definition of regulated activity with the aim of making it more easily understood by those who must apply it.
Other
Harrington WCA Review (Year 2) — Rec 19
DWP Operations should improve internal communications to ensure that each part of the claims process and Personal Advisers have a broad understanding of the policy intent of the WCA, what a Fit for Work decision means for a claimant and the support available to them.
Employment & Work
Wessely Review — Rec 111
Government should consult on the ability of parents to consent to admission and treatment for those under 16.
Health & Social Care
Accepted
Wessely Review — Rec 110
Young people aged 16 or 17 should not be admitted or treated on the basis of parental consent. The MCA (LPS) or MHA should be used as appropriate if they are unable to consent to their treatment.
Health & Social Care
Accepted
Wessely Review — Rec 109
In young people under 16, competence should be understood in this context as the functional test under the Mental Capacity Act, although without the presumption of capacity that applies in relation to those over 16.
Health & Social Care
Accepted
Wessely Review — Rec 108
Legislation and guidance should make clear that the only test that applies in relation to those aged 16/17 to determine their ability to make decisions in relation to admission and treatment is that contained in the Mental Capacity Act.
Health & Social Care
Accepted
Modern Slavery Act Review — Rec 77
Finally, professional bodies need to reflect in their guidance to members that where there is evidence that someone might be a victim of trafficking, it is likely to be in their client’s best interests to disclose this immediately, and the Crown must be given adequate time to conduct their enquiry.
Justice & Legal
Accepted
Stevenson/Farmer Review — Rec 38
Given the clear links between mental health and productivity, we invite 'Be the business' and similar initiatives to incorporate employee mental health in their tools and information.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 26
We recommend that the Government consider legislative change to enhance protections for employees with mental health conditions, particularly fluctuating mental health conditions and clarify the role of employers in providing reasonable adjustments.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 25
We recommend that public bodies encourage their suppliers to implement the mental health core standards.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 21
We recommend the formation of a mental health online information portal, co-produced by the voluntary, public and private sector, to promote best practice and enable employers of all sizes to implement the mental health core and enhanced standards.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 14
We recommend that all public sector workforces should implement the mental health core and enhanced standards.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 12
We recommend that the Health and Safety Executive builds on its risk assessment guidance and Management Standards approach by highlighting how these actions will help employers deliver key parts of the mental health core standards.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 11
We recommend that the Health and Safety Executive revise its guidance to raise employer awareness of their duty to assess and manage work-related mental ill-health.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 5
We recommend that industry groups provide guidance and support to enable employers to implement the mental health core standards, and take steps to support increased employer transparency and accountability on workplace mental health.
Employment & Work
Accepted
Stevenson/Farmer Review — Rec 1
We recommend that all employers, regardless of workplace type, industry or size adopt the mental health core standards. This will ensure 'breadth' of change across the UK workforce and lay the foundations for going further, and can be delivered proportionally depending on the size and type of business. The mental …
Employment & Work
Accepted
Timpson Review — Rec 23
DfE should use best practice on managed moves gathered by this review and elsewhere to enable it to consult and issue clear guidance on how they should be conducted, so that they are used consistently and effectively.
Education
Accepted
Timpson Review — Rec 1
DfE should update statutory guidance on exclusion to provide more clarity on the use of exclusion. DfE should also ensure all relevant, overlapping guidance (including behaviour management, exclusion, mental health and behaviour, guidance on the role of the designated teacher for looked after and previously looked after children and the …
Education
Accepted
Windrush Review — Rec 21
Building on the Law Commission's review of the Immigration Rules the Home Secretary should request that the Law Commission extend the remit of its simplification programme to include work to consolidate statute law. This will make sure the law is much more accessible for the public, enforcement officers, caseworkers, advisers, …
Immigration
Accepted
Windrush Review — Rec 18
The Home Office should establish more and clearer guidance on the burden and standard of proof particularly for the information of applicants, indicating more clearly than previously how it operates and what the practical requirements are upon them for different application routes. The decision-making framework should include at least guidelines …
Immigration
Accepted
Owens Review — Rec 32
That HMPPS communicate out to all staff action that has been undertaken as a result of this review, to showcase positive action and encourage improvements.
Justice & Legal
Owens Review — Rec 9
The Ministry of Justice and HMPPS to review the policy on Release License. The aim should not be to determine retrospectively which interpretation was 'correct,' but to recognise that frontline staff cannot be expected to interpret contradictory or opaque policies, especially where the stakes are high. Operational staff require clear-cut, …
Justice & Legal
Owens Review — Rec 6
Introduce a clear process at operational level by which staff can escalate conflicting use of 'Not for Release' markers before a discharge or release is authorised.
Justice & Legal
Owens Review — Rec 5
HMPPS should clarify at an operational level when 'Not for Release Markers' should be used and mandate the checking of all 'Not for Release' markers during release and discharge processes.
Justice & Legal
Owens Review — Rec 4
That HMPPS clarify operational guidance on what a high-profile alert means, when it should be used, what should happen as a result during the release process and/or other prisoner movements and use, triggering a clear sequence of events.
Justice & Legal
PHSO casework decisions(2)
P-002414 — An independent provider in the Hackney area
Mrs E complained an independent provider could not identify staff who saw her husband's blue nails and believed midazolam led to his death.
NHS in England
Jan 2024
P-002549 — Chelsea and Westminster Hospital NHS Foundation Trust
Mrs Q complained staff failed to drain her husband's NG tube collection bag and ensure its correct placement, leading to acid aspiration, pneumonia, and a traumatic death.
NHS in England
Partly Upheld
Apr 2024
LGO / SPSO decisions(224)
22-001-289 — Stoke-on-Trent City Council
Summary: Mrs X complained about the Council’s application of its home to school transport policy. There was fault in the way the Council conducted its stage 2 appeal which caused Mrs X uncertainty. There was also delay holding the panel. The Council has agreed to apologise to Mrs X, reconvene …
LGO (Local Government & …
Education
Upheld
Oct 2022
22-000-526a — Akari Care (22 000 526a)
Summary: Mr B complained about the actions of a Care Provider because he says his late mother’s rings went missing in one of its nursing homes. He also said the Council did not do enough to investigate the matter. We did not find fault by the Council. The Care Provider …
LGO (Local Government & …
Health
Upheld
Oct 2022
22-011-627 — London Borough of Brent
Summary: We will not investigate this complaint about a Council Officer’s use of the incorrect pronoun when writing to the complainant. We are satisfied the Council’s response was a proportionate to the issues raised.
LGO (Local Government & …
Other Categories
Upheld
Dec 2022
24-003-887 — London Borough of Hackney
Mrs D complained the Council refused to renew her Blue Badge. Our investigation has found fault in the advice given to staff who work at the Council’s assessment centre and assess Blue Badge applications.
LGO (Local Government & …
Adult Care Services
Upheld
Apr 2025
24-020-460 — Rother District Council
Summary: We will not investigate this complaint about a lack of policy and procedures for staff carrying out planning enforcement investigations and actions. This is a matter which affects all or most of the people in the Council’s area and is therefore outside our jurisdiction.
LGO (Local Government & …
Planning
Apr 2025
24-015-681 — Bournemouth, Christchurch and Poole Council
Summary: Mx X complained the Council failed to adhere to reasonable adjustments agreed for their disability between August 2023 and December 2024. There was no fault in how the Council adhered to the agreed reasonable adjustments. There was fault in the Council’s communication and record keeping about the reasonable adjustments. …
LGO (Local Government & …
Other Categories
Upheld
Aug 2025
24-019-309 — St Albans City Council
Summary: Mr B complained that the Council had not followed its own policy when it banned him from trading at one of its markets. We found the Council did not follow its policy on giving warnings, but this did not cause Mr B injustice as he had been allowed to …
LGO (Local Government & …
Other Categories
Upheld
Sep 2025
24-003-010 — Medway Council
Summary: There was fault by the Council in failing to seek confirmation of whether a pupil had previously hit staff on school transport before reaching a decision about the nature of transport required. The Council will apologise, provide a payment to remedy injustice and make service improvements. The complaint is …
LGO (Local Government & …
Education
Upheld
Nov 2024
201103124 — Scottish Prison Service
Mr C complained because he said his parole information was not delivered to him in the normal way - it was hand delivered by a unit manager instead of being sent in an envelope. Mr C also said he was not given enough time to submit his representations to the …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Mar 2012
201103108 — Scottish Prison Service
Mr C complained that the prison governor failed to properly investigate his complaint about prison staff referring to him by his surname and not including his title. The governor had responded by asking one of the managers to raise this with staff. We confirmed with the SPS that the manager …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Apr 2012
201203348 — Scottish Prison Service
Mr C complained about the way he was treated by a prison officer in the reception area of a prison he was visiting. He was unhappy with the prison's complaints handling, and in particular, felt the prison failed to investigate his complaint appropriately. He was also unhappy because the prison …
SPSO (Scottish Public Se…
Prisons
Upheld
Jun 2013
201204540 — Lothian NHS Board
Ms C's late mother (Mrs A) was treated in hospital as an in-patient for illnesses that included pneumonia and chronic heart failure. Ms C complained that during that time the hospital communicated inadequately with her and other family members about Mrs A's medical condition. In particular Ms C said that …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2014
24-001-211 — Dorset Council
Summary: We will not investigate this complaint about how the Council dealt with a report that health and safety procedures were not being followed at a workplace. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Jun 2024
24-005-075 — London Borough of Tower Hamlets
Summary: There was fault in the way the Council responded to the complainant’s reports of anti-social behaviour (ASB) in her building. The Council did not give proper consideration to the complainant’s needs or to its full toolkit of powers for tackling ASB, did not follow its own ASB policy as …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
24-020-673 — Thurrock Council
Summary: Mr D complains the Council failed to fully consider relocating communal waste bins. I do not have contemporaneous evidence of how the Council assessed the site and considered Mr D’s request. I have upheld the complaint and asked the Council to carry out a new assessment, which it should …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
24-015-859 — Dacorum Borough Council
Summary: We have no grounds to criticise the Council’s decision that a noise does not amount to a statutory nuisance. However, there was fault by the Council, because it has considered irrelevant factors as part of its decision-making. This did not cause an injustice to the complainant, but the Council …
LGO (Local Government & …
Environment And Regulation
Upheld
Sep 2025
23-016-869 — Surrey County Council
Summary: Miss X complained about how the Council administers school transport applications for children in her village. We do not find fault with how the Council assesses these applications. We find the Council at fault for delays in considering Miss X’s appeal, and for providing incorrect information but we find …
LGO (Local Government & …
Education
Upheld
Nov 2024
201200240 — A Medical Practice in the Ayrshire and Arran …
Miss C had her tonsils removed. After the procedure, she was in a great deal of pain and unable to eat and drink. Five days after the procedure, she went to see her GP about these symptoms. Miss C said that her GP just looked at the back of her …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2012
201300417 — South Ayrshire Council
Mr and Miss C complained that a neighbour had constructed an entranceway that extended along the road verge to the entrance of a field that Mr and Miss C rent. They complained that this in effect increased the level of the verge, making it difficult to access the field with …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2013
201203255 — An NHS Board
Ms C is a transgender woman undergoing gender reassigment (a process of changing from man to a woman). She complained that the assessment process for acceptance for gender reassignment surgery took too long and was unreasonably delayed. She started going to the relevant clinic, attending regularly over the following three …
SPSO (Scottish Public Se…
Health
Partly Upheld
Nov 2013
201100497 — Dumfries and Galloway Council
The council had approved a planning application for a new house on a site close to Mr C's home, although the application was subject to certain planning conditions. Mr C complained that since then the council had failed to enforce a condition about a landscaping scheme. He also complained that …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Nov 2013
201301789 — South Lanarkshire Council
Mr C complained about the council's decision to reschedule road resurfacing work. He complained that they had not recorded the feedback on which their decision was based, or recorded the decision. Our investigation, however, found no evidence that the council had any obligation to record every piece of feedback received …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Dec 2013
201300737 — Renfrewshire Council
Mr C complained about the way the council handled his claim for compensation after he damaged his suit on a protruding screw in a council-owned building. He also complained about their decision to limit the sum they agreed to pay him to the cost of replacing his jacket, rather than …
SPSO (Scottish Public Se…
Local Government
Upheld
Dec 2013
201300574 — Business Stream
Mr C leased and operated a pub that shared its water supply with a residential property. He complained that Business Stream unreasonably delayed in issuing their initial invoice he had run the pub since 2007 and only received an invoice in 2010 and that when it arrived it …
SPSO (Scottish Public Se…
Water
Partly Upheld
Jan 2014
201405793 — Scottish Prison Service
Mr C complained because he said the prison unreasonably refused to progress him to open (lowest security) conditions. Instead, the risk management team (RMT) - the group responsible for considering whether a prisoner is suitable to progress to less secure conditions - decided that Mr C should transfer to the …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jul 2015
201404931 — University of Edinburgh
Mr C, a postgraduate student, had complained to the university a number of times about a range of matters. When he submitted two new complaints for investigation, as he did not accept the outcome of the front-line resolution, the university responded that they had decided to restrict his access to …
SPSO (Scottish Public Se…
Education
Not Upheld
Jul 2015
201403970 — West Lothian Council
Mr C complained that his son's school had introduced a new policy on excursions that impacted unfairly on his son, who had a disability. Mr C said the school failed to consult him about the new policy and failed to take into account his son's needs and the Equality Act …
SPSO (Scottish Public Se…
Local Government
Upheld
Jul 2015
201401497 — Scottish Prison Service
Mr C complained to us about the Scottish Prison Service (SPS)'s handling of his post programme report (the report) which was required eight weeks after the completion of his treatment programme. Mr C complained that, due to the delay in completing the report, his tribunal hearing had been adjourned and …
SPSO (Scottish Public Se…
Prisons
Upheld
Jul 2015
201204983 — Dumfries and Galloway NHS Board
Ms C had cognitive and communication problems. Following poor experiences with her GP practice, she asked to be deregistered. However, she subsequently found it difficult to register with a new practice. Before registering with a new GP, Ms C sought reassurance that they would make reasonable adjustments in light of …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2015
201403076 — Tayside NHS Board
Mrs C said her son was admitted to Ninewells Hospital with a suspected infectious disease and was kept in hospital for two nights. Mrs C said she was told that her son's treatment would be free, but during the discharge process she was advised she would have to pay for …
SPSO (Scottish Public Se…
Health
Not Upheld
Aug 2015
201304125 — Dumfries and Galloway Council
Mr C lives near a holiday chalet park with a history of planning applications and amendments. The council had approved a retrospective planning application, subject to four conditions. He complained to us about the way they handled a number of planning issues, including a failure to follow correct development plan …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Aug 2015
201501567 — Glasgow City Council
Mr C complained to us on behalf of his client (Miss A) who had been refused an application made to the council for a crisis grant. The reasons for the refusal were that she had already received a grant in the preceding 28 days and her circumstances had not changed. …
SPSO (Scottish Public Se…
Local Government
Partly Upheld
Sep 2015
201407836 — Scottish Borders Council
Mr C complained that a council officer unreasonably barred his entry into a public event that was being held in a council facility. He also complained that the officer's behaviour at the time was inappropriate. He then complained to the council about this incident but was dissatisfied with their investigation …
SPSO (Scottish Public Se…
Local Government
Not Upheld
Sep 2015
201508271 — Scottish Prison Service
Mr C complained that a prison manager unreasonably failed to take action to notify a family member that he had been assaulted in prison and taken to hospital. Scottish Prison Service (SPS) rules state that requests from prisoners for a relative or friend to be informed must be actioned if …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Jan 2017
201603064 — Edinburgh Napier University
Mr C complained on behalf of his daughter (Miss A), a student at the university. Mr C's complaints were about the university's handling of the Fitness to Practise (FtP) process in relation to Miss A, and the university's handling of his complaint. We found that, in general terms, the FtP …
SPSO (Scottish Public Se…
Education
Partly Upheld
May 2017
201805111 — Perth and Kinross Council
Mr C was admitted to hospital following a stroke. In order to prepare for his discharge, the council arranged for a homecare service to be put in place. Due to his level of personal savings, Mr C was advised that he would be required to pay the full amount of …
SPSO (Scottish Public Se…
Local Government
Upheld
Jul 2019
201705215 — Tayside NHS Board
Mr C complained about the actions of a court appointed psychologist who interviewed him after he had been convicted of an offence. In their response to the complaint the board set out the reasons why the court decided to appoint the psychologist. They also explained that specific information was required …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2019
24-018-275 — West Sussex County Council
Summary: Miss Y complained about a support service commissioned by the Council for people in its area recovering from alcohol and drug misuse and provided to Mr X, her late father. We have found fault, causing injustice, by the service provider in failing to: follow its proper procedure in response …
LGO (Local Government & …
Other Categories
Upheld
Dec 2025
201808032 — Highland NHS Board
Mr C complained about the board's actions regarding his access to overnight accommodation at a facility provided by them, whilst Mr C was attending New Craig Psychiatric Hospital for treatment. Mr C said that the board unreasonably failed to provide him with overnight accommodation when he attended the hospital. He …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2020
201800154 — University of Edinburgh
C was enrolled on a programme at the University of Edinburgh. C complained about the university's response to reports of bullying during their placements. We found that the university took reasonable action to address C's concerns regarding the difficulties they experienced on placement, in line with the relevant university procedures. …
SPSO (Scottish Public Se…
Education
Not Upheld
Oct 2020
202003157 — Aberdeen City Health and Social Care Partnership
C complained on behalf of A (an adult who lives as a tenant in supported accommodation provided by the partnership) about the partnership’s communication with A’s welfare guardian (B). A, B and C are siblings. Following incidents between A and other individuals, B emailed A’s carers to make a suggestion …
SPSO (Scottish Public Se…
Health and Social Care
Upheld
Oct 2021
202410198 — Lothian NHS Board - Acute Services Division
C complained that the board failed to communicate appropriately with their partner (A) regarding charges for treatment. A is a non-UK resident and was charged for non-urgent treatment at hospital following an accident. C complained that A was not informed of the financial liabilities they would incur prior to their …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2025
202500059 — Greater Glasgow and Clyde NHS Board - Acute …
C complained that the board's communication around their spouse (A)'s care and treatment was unreasonable. C complained about a lack of face-to-face appointments, delays and the board not following their diagnostic pathway. C said that they were informed of A's prostate cancer over the phone, with no support provided to …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2026
202304648 — Dumfries and Galloway NHS Board
C complained that the board failed to reasonably communicate with them about the care and treatment of their parent (A). C said that the board failed to inform them that a lump had been found on A’s breast while A was in hospital. A had been due to go into …
SPSO (Scottish Public Se…
Health
Not Upheld
Feb 2026
PSOW-202200329 — Adra
Miss X complained that she had been a subject to hate, abuse, discrimination and harassment by her neighbours. Miss X also complained that despite putting a complaint forward to the Association, the Association had not yet responded to her concerns. The Ombudsman was concerned that Miss X had yet to …
PSOW (Public Services Om…
May 2022
PSOW-202309088 — A GP Practice in the area of Swansea …
Mr B complained because he was unhappy with the actions of a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) following the way he was spoken to during a telephone call with a doctor. He was unhappy that his written complaint was responded to by …
PSOW (Public Services Om…
Health
Apr 2024
21-011-741 — London Borough of Hillingdon
Summary: Ms X complained about the Council’s decision on her son’s school transport, resulting in distress to her son and inconvenience to her. We find the Council at fault for not following its published process, but this did not affect the Council’s decision making. We recommend the Council apologise to …
LGO (Local Government & …
Education
Upheld
Mar 2022
22-000-389 — Leicester City Council
Summary: We will not investigate this complaint about the Council’s failure to supply personal protective equipment during a three-month period from November 2021. The Council’s apology is sufficient for the injustice caused and we could not add to its investigation or achieve a different outcome by investigating.
LGO (Local Government & …
Adult Care Services
Apr 2022
22-009-607 — Devon County Council
Summary: We will not investigate this complaint that the Council will not reimburse Miss X’s taxi fare as there is insufficient injustice to warrant our involvement.
LGO (Local Government & …
Other Categories
Nov 2022
22-010-621 — London Borough of Hackney
Summary: We will not investigate this complaint about the Council issuing the complainant with a Fixed Penalty Notice. This is because we are unlikely to achieve anything more to add to the Council’s investigation.
LGO (Local Government & …
Environment And Regulation
Nov 2022
Domestic Homicide Reviews(1404)— showing 50 strongest matches
Bury — recommendation 2.
There is a need for all GP practices to establish a DVA policy and procedure. This has been a previous recommendation and needs to be audited to assess compliance. This needs to include a system for recording health indicators for domestic abuse in line with the Guidance for responding to …
North Manchester Clinical Commissioning Group
Bury — recommendation 3.
The Head of the PPD should ensure that awareness around policy and procedure where DV markers are in place be reinforced for all staff throughout the response policing establishment.
Greater Manchester Police
Greater Manchester Police
Bromley — recommendation 4.4.6
All Health agencies to implement and use the NICE guidance to support the delivery of recommendations within this review as they relate to Health.
All Health agencies
Bromley — recommendation 4.4.4
Local agencies must review or introduce core competencies, training plans, and policies and procedures in relation to domestic abuse, and provide these to the Community Safety Partnership (CSP) and local Children and Adult Safeguarding Boards.
Local agencies | Bromley Community Safety …
Kingston upon Hull — recommendation 20
Within 12 months, the practice will review and update the domestic abuse policy and guidance, this will include roles and responsibilities of the Domestic Abuse/Violence lead.
GP Practice
Lambeth — recommendation 4.8.4
Recirculate and discuss Social Care threshold document
Guy’s & St Thomas’ Hospital
Guy's and St Thomas' …
Portsmouth — recommendation 2
Highlight through internal communications SCAS responsibility when dealing with DA incidents and the interface with police.
SCAS
South Central Ambulance Service …
Lincoln — recommendation Recommendation 3 ii)
The Safer Lincolnshire Partnership and the Lincolnshire Domestic Abuse Partnership should seek assurance from all agencies that their staff are aware of the impact that Domestic Abuse has on Safeguarding Children. That the agencies also ensure that any perpetrator risk assessments feed into the safety planning around any children in …
Safer Lincolnshire Partnership | Lincolnshire Domestic …
Lincoln — recommendation Recommendation 1
The Safer Lincolnshire Partnership (SLP), Lincolnshire Domestic Abuse Partnership (LDAP) and the Lincolnshire Safeguarding Children Partnership (LSCP) need to coordinate the raising of professionals’ awareness, knowledge and understanding of: i) the Domestic Violence Disclosure Scheme, Domestic Violence Protection Notices and Domestic Violence Protection Orders (to be led by Lincolnshire Police). …
Safer Lincolnshire Partnership | Lincolnshire Domestic …
Lincolnshire Police
Lincoln — recommendation i)
Staff within the Hostel need to be confident in their responsibility to report disclosures of concern robustly and consistently. The service has evidence of regularly reporting safeguarding concerns appropriately, however, in this case staff felt reassured by (1) how the perpetrator presented within the service and (2) the response from …
Salvation Army
Lincoln — recommendation 1
It is accepted that there are gaps in front line Officers’ knowledge of DVDS, DVPN’s and DVPO’s and Lincolnshire Police have instigated further DA Matters training to all front line staff commencing in February 2022 where the use of DVPNs and DVDS will be covered. The subject of DVDS has …
Lincolnshire Police
Lincolnshire Police
Cheltenham — recommendation GHCNHST.2
Development of a ‘notice, ask, refer’ reminder card for staff is being progressed by the Domestic Abuse Lead in the Trust.
Gloucestershire Health and Care NHS Trust
Gloucestershire Health and Care …
Doncaster — recommendation 2
IDVA Process Guide is updated.
Doncaster Council IDVA Service
Sheffield — recommendation STHFT 4
The STHFT ED should remind all staff of the Standard Operating Procedure for the reporting of gun and knife crime and ensure all staff working within the Emergency Department and Minor Injuries are made aware of their responsibilities for reporting such incidents to police. The SOP could include responsibilities for …
Sheffield Teaching Hospitals Foundation Trust (STHFT)
Sheffield — recommendation SYP 3
Operational update / brief around the importance of completing a DASH and even submit where DA is suspected, this is regardless of whether the victim engages and assists by answering the questions.
SYP
South Yorkshire Police
Sheffield — recommendation 7
The STHFT ED should remind all staff of the Standard Operating Procedure for the reporting of gun and knife crime and ensure all staff working within the Emergency Department and Minor Injuries are made aware of their responsibilities for reporting such incidents to police. The SOP could include responsibilities for …
STHFT
Doncaster — recommendation 4
Review and update the YAS policy ‘Domestic Abuse: Management Guidance’, to reflect the strengthened pathways for assessment and referral.
Yorkshire Ambulance Service
Yorkshire Ambulance Service NHS …
Doncaster — recommendation 6
All staff will be reminded of the need to consider domestic abuse within the context of safeguarding, including seeking guidance from the Safeguarding Team and utilising protection planning.
Rotherham Doncaster & South Humber NHS …
Rotherham Doncaster and South …
Norfolk — recommendation 9
That all agencies review policies and procedures to ensure that they include the provisions of the Domestic Abuse Act 2021.
East London NHS Foundation Trust | …
East London NHS Foundation …
Norfolk — recommendation 6
That housing services involved in the DHR review their policies and develop new practice to consider economic abuse when assessing housing needs.
Norwich City Council | L&Q Housing …
Norwich City Council
Gloucester — recommendation 8
Ensure officers are aware of Crown Prosecution Service advice that proof of service of a Non-Molestation Order is only required where the suspect raises knowledge of the Order as an issue in interview.
Gloucestershire Constabulary
Gloucestershire Constabulary
Kent — recommendation 17
The NICE guidance regarding pain management is to be circulated to GPs within Kent and Medway with a request that they review their patients in light of the new guidance. This recommendation links into the Kent and Medway SAR David (2021) which also made a recommendation regarding the new NICE …
Kent & Medway ICB
NHS Kent and Medway …
Doncaster — recommendation 3
That the Safer Stronger Doncaster Partnership ensures that agencies policies and procedures identify all aspects of domestic abuse and that all staff are aware of their roles and responsibilities in respect of implementing these policies.
Safer Stronger Doncaster Partnership
Kent — recommendation 6
To provide each GP practice with an up to date adult safeguarding policy that reflects national and local guidance and best practice to guide and support staff in responding to victim and perpetrators of domestic abuse and self-neglect.
Kent and Medway ICB’s/NHS England
NHS Kent and Medway …
Tower Hamlets — recommendation 7.1.4
The Central East BCU SLT reinforce the requirement for all staff: • To understand the Vulnerability and protection of adults at risk policy; • To understand the VAF; and • To complete ACN Merlin reports where they have identified vulnerability whether they are a victim, witness, suspect or member of …
Metropolitan Police Service
Metropolitan Police Service
Tower Hamlets — recommendation 7.1.3
The North East SLT reinforce the requirement for all staff: • To understand the Vulnerability and protection of adults at risk policy; • To understand the VAF; and • To complete ACN Merlin reports where they have identified vulnerability whether they are a victim, witness, suspect or member of the …
Metropolitan Police Service
Metropolitan Police Service
Swindon — recommendation 28
All personnel should be reminded of the policy that: 1. The “Missed Appointment Matrix” is to be followed for all clients – especially prior to closing. 2. Workers to double check hard copy file for client’s preferred method of contact and follow this course of action first. 3. If paperwork …
Swindon Drug and Alcohol Service (CGL)
Swindon — recommendation 5
For all members of the Swindon Intensive Team to be aware of patients who have a rapid access plan into services and to be aware of its purpose.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Plymouth — recommendation 12
Staff in School 2 and School 3 must be reminded of the LSCB escalation policy.
School 2 | School 3
Warrington — recommendation 19.22
To review policies and procedures in relation to dealing with prisoner recall orders.
Cheshire Constabulary
Cheshire Constabulary
Warrington — recommendation 19.13
Staff should be made aware of their statutory and professional obligations and reminded of their professional responsibilities with regard to documentation and record keeping.
Warrington and Halton Hospitals NHS Foundation …
Warrington and Halton Teaching …
Warrington — recommendation 19.4
Warrington Community Safety Partnership should seek assurance from its constituent partners and third sector agencies that they commission that an appropriate mechanism is in place to ensure that domestic abuse and safeguarding policies are embedded in practice.
Warrington Community Safety Partnership
Warrington — recommendation 19.3
Warrington Community Safety Partnership should seek assurance from it’s constituent agencies and the commissioners of Pathways that the purpose and status of a VPA is consistently understood across the partnership.
Warrington Community Safety Partnership
Ashfield — recommendation 5.2
It is recommended that Nottinghamshire Police raise awareness of the change in its policy in July 2018 which means that, in this case a risk assessment would have been undertaken. Awareness should be raised in order that officers understand that incidents where a relationship has come to an end or …
Nottinghamshire Police
Nottinghamshire Police
Ashfield — recommendation 5.1
It is recommended that Nottinghamshire schools have a a clear policy about how they will respond when they are made aware that parents have separated to ensure that there is clarity about how issues, such as collection of children and altercations in the playground, will be dealt with.
Nottinghamshire Schools
Kent — recommendation 7
Current policy regarding the management of a breach of bail conditions/harassment orders should be reviewed. Specific measures should be introduced that ensure any breaches are actioned in a timely manner.
Kent Police
Kent Police
Kent — recommendation 2
To ensure staff awareness of the Care Act 2014 and the need for carer’s assessments to be provided where appropriate.
Private Healthcare Provider
Kent — recommendation 1
Ensure staff awareness of the impact of being a carer and when the need for a carer’s assessment is required. (Kent & Medway Safeguarding Adults Board (KMSAB), GPs and Local Hospice.)
Kent Community Safety Partnership | NHS …
Pembrokeshire — recommendation 19
To develop a briefing that can be shared with members of DHR Panels outlining role, responsibilities and expectations
Regional VAWDASV Board
Pembrokeshire — recommendation 11
Learning from this IMR be shared within the organisation to support the understanding of o Expected practice as it relates to the health and social care considerations of all patients and service users and o The principles of Social Services and Wellbeing (Wales) Act 2014 and Violence against Women, Domestic …
Welsh Ambulance Service NHS Trust
Welsh Ambulance Services NHS …
Swindon — recommendation 16
Operational officers will be reminded of Force Policy that if either drugs or alcohol are key factors in an offence for which an individual has been arrested, the arrested person should be signposted to a substance abuse support service and this should be recorded on the Custody Record.
Wiltshire Police
Wiltshire Police
Swindon — recommendation 8
That all supervisory personnel are reminded of the statutory requirements to respond fully to requests for information from Domestic Homicide Reviews
Swindon Borough Council Children Families and …
Oxford — recommendation 7
In circumstances where there may be reason not to follow Reducing the Risk practice guidelines Reducing the Risk will ensure a robust process of decision making.
Reducing the Risk of Domestic Violence
Oxford — recommendation 5
Reducing the Risk should remind all designated MARAC officers of processes for simultaneous referral to IDVA and MARAC.
Reducing the Risk of Domestic Violence
Oxford — recommendation 4
Reflect the Government’s guidance which extends the definition that domestic abuse can apply to 16 and 17 year olds.
Bournemouth Church Housing Association
Hillingdon — recommendation 4.5.2
SHP to ensure that all partner agencies conduct an internal review of their domestic violence/abuse policies and procedures in relation to how they identify, risk assess, refer and respond appropriately to victims, particularly those who don’t engage and/or are subject to coercive control, and make changes as appropriate. This must …
Safer Hillingdon Partnership (SHP)
South Tyneside — recommendation AP15
All officers and staff responding to and investigating domestic abuse are to be reminded that the Northumbria Police Procedure for Investigating Domestic Abuse clearly states that enquiries should be intrusive and tenacious in establishing the true facts.
Northumbria Police
Northumbria Police
South Tyneside — recommendation AP14
All officers and staff responding to, and investigating, domestic abuse are to be reminded that ‘Proportionate Investigation does not apply to reports of domestic abuse. All reports of domestic abuse are to be thoroughly and robustly investigated’ as clearly stated in current force policy on crime investigation.
Northumbria Police
Northumbria Police
South Tyneside — recommendation 18.2.5
In relation to investigating domestic abuse, all Officers and staff responding to and investigating domestic abuse are to be reminded that the Northumbria Procedure for Investigating Domestic Abuse clearly states that enquiries should be intrusive and tenacious in establishing the facts. Both parties should be spoken to in a domestic …
Northumbria Police
Northumbria Police
South Tyneside — recommendation 18.2.5
All Officers and staff responding to, and investigating, domestic abuse are to be reminded that ‘Proportionate Investigation does not apply to reports of domestic abuse. All reports of domestic abuse are to be thoroughly and robustly investigated as clearly stated in the current Force policy on crime investigation. This can …
Northumbria Police
Northumbria Police
ISC reports(2)
Detainee Mistreatment and Rendition: Current Issues
Companion report examining current policy and guidance on detainee mistreatment and rendition.
Special Report
Jun 2018
Detainee Mistreatment and Rendition: 2001-2010
Inquiry into the involvement of, and knowledge held by, the UK intelligence agencies in the mistreatment and rendition of detainees between 2001 and 2010.
Special Report
Jun 2018