Staff rota communication
Failures in communicating staff rota changes directly to staff members, relying solely on electronic system updates.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
4 inquiry recs
94 PFD reports
6 committee recs
5 HSSIB recs
15 CQC actions
2 HMICFRS recs
2 ICIBI recs
2 PPO recs
10 IOPC recs
43 IMB recs
3 IMB reports
1 Article 2 learning point
3 detention investigation recs
5 DHR recs
5 LGO/SPSO decisions
1 CQC enforcement action
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(4)
LADB-46 — Establish and apply criteria for signallers exceeding maximum 72-hour work week
Recommendation: Railtrack management should set out the criteria for allowing signallers, in exceptional circumstances, to exceed the maximum of 72 hours of work per week, and ensure that these criteria are, and continue to be, correctly applied (para 12.19).
Unknown
R50 — 24/7 IPC cover
Recommendation: Health Boards should ensure that there is 24-hour cover for infection prevention and control seven days a week, and that contingency plans for leave and sickness absence are in place.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
IHRD-18 — On-Call Consultant Display
Recommendation: The names of all on-call consultants should be prominently displayed in children's wards.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
LADB-12 — Increase driver briefing frequency with safety as primary agenda item
Recommendation: Thames Trains should increase the frequency of the briefing of drivers with a view to ensuring that each driver has a face to face meeting with his or her driver standards manager at least monthly, if not more often, and …
Unknown
Prevention of Future Deaths reports(94)— showing 50 strongest matches
Nicola Matthews
Concerns: The coroner identified incomplete documentation of ward round decisions and a lack of clear, documented follow-up arrangements for patients discharged from inpatient care, particularly those at risk of self-harm. This meant staff lacked clarity on discharge plans and medication.
Overdue
Susan Jill Hammond
Concerns: The coroner noted that written allergy warnings on hospital documentation were overlooked and suggested clearer indications on patient files. Concerns were also raised about inadequate handovers during patient transfers, where the accompanying nurse had insufficient knowledge of the patient's condition.
Response (United Lincolnshire Hospitals NHS): • The prescription chart was modified to include a red-coloured section for "Drug allergies and sensitivities" with expanded space for details. • A structured handover tool, SBAR, was implemented for … (AI summary)
Responded
Sean Seabourne
Concerns: The coroner noted insufficient formal communication and clarity of roles between mental health teams, which meant critical information about a patient's settled plans to kill himself was not adequately shared or acted upon.
Overdue
Christopher James Morgan
Concerns: The coroner raised concerns regarding the lack of communication with family and carers before changing a patient's risk level for leave, and the absence of a clear policy on staff-to-patient ratios for escorted leave from psychiatric wards.
Overdue
Joanne Manning
Concerns: The coroner raised concerns about the lack of established communication procedures between general practitioners and secondary care prescribers of methadone, which led to a psychiatrist not receiving crucial patient medical information from the GP practice.
Overdue
Barbara White
Concerns: The coroner noted a lack of clinical observations and an incorrect PARS score delaying medical intervention. Concerns also included unescalated insufficient staffing on the surgical unit and communication gaps during handover, affecting subsequent clinical consideration.
Overdue
Brian Belfield
Concerns: The coroner identified a lack of robust systems for tracking and reconciling race participant numbers, meaning a missing runner was not identified. Concerns also included insufficient communication between race control and marshals.
Overdue
Margaret Walker
Concerns: Concerns were raised regarding the delay in obtaining and sharing details of Mrs Walker's previous diabetes medication and acceptable blood test results. Her medical condition and blood test readings were not appropriately recorded in clinical notes, and an available defibrillator was not applied before ambulance personnel arrived.
Response (5 Boroughs Partnership NHS Foundation Trust): • The Trust stated it had reviewed its medicines reconciliation policy and processes and would issue further guidance. • The Trust addressed staff competency in clinical note recording through supervision … (AI summary)
Responded
Winifred Dennis
Concerns: The coroner identified that the transfer of patients between community nursing teams, due to moves between care homes, lacked a formal handover document. This meant important non-clinical information, such as the use of an airflow mattress, was not consistently communicated, potentially reducing optimal patient care.
Response (Kent Community Health NHS Trust): • A formal process for transferring care between community nursing teams has been devised. • A working group has been established to revise policies and procedures and monitor transfer of … (AI summary)
Responded
Ryan Boyle
Concerns: The coroner identified a need for improved training for force control operators on police pursuit policies and responsibilities. Concerns were also raised regarding the lack of an efficient notification system for pursuits and insufficient staffing on the 'Force desk'.
Response (Surrey Police): • The Force reviewed its pursuit management guidance and revised FCR Pursuit and TPAC Refresher training materials for all staff levels. • A "Call Supervisor" button was installed on FCR … (AI summary)
Responded
Dayani Chauhan-Ahmed
Concerns: The coroner noted ineffective communication regarding the length of the second stage of labour to senior staff due to an unmonitored whiteboard system. There was also uncertainty among midwifery and medical staff concerning the updated escalation policy and adherence to its time limits.
Response (University Hospital of Leicester NHS Trust): • The Trust committed to reviewing and strengthening guidelines for the management of the second stage of labour, including guidance on using the emergency buzzer and ensuring sight of CTG … (AI summary)
Responded
Antonio Allen
Concerns: Midwives were not contactable for a booked home birth, resulting in family members assisting with the delivery before midwives arrived after the birth.
Response (Central Manchester University Hospitals NHS): • The clinical team was instructed to review the case. • Women planning home births are now provided with two telephone numbers. • A standard operating procedure is in place … (AI summary)
Responded
Awa Jeng
Concerns: Insufficient monitoring and medical review for a high-risk patient led to a failure in following instructions for repeat blood tests and checks. The report also highlights a lack of clear action to address concerns about handover of responsibilities between shifts.
Response (Barts Health NHS Trust): • A section for signing and dating has been added to the handover sheet for audit and transparency purposes. • Instructions have been issued to junior doctors in orthopaedics and … (AI summary)
Responded
Daniel Strickland
Concerns: The coroner raised concerns regarding the lack of written handover between supervisors, inaccurate detail in records, and the daily log being inaccessible and misleading, hindering the passage of significant medical information.
Overdue
Archie Hexall
Concerns: The coroner noted a breakdown in communication between midwives regarding signs of respiratory distress, and the initial observation records were not retained. Parents were also not informed of concerns about their child's breathing, limiting their opportunity to contribute to care.
Response (Lewisham Greenwich NHS Trust): • Staff have been reminded that all loose documentation must be secured into the main clinical notes. • The Trust is embedding the SBAR communication tool within the maternity service, … (AI summary)
Responded
Tamara Holboll
Concerns: The coroner identified a lack of precision in the trust's communication protocols, noting that staff lacked clear instructions on how to action identified communication needs effectively.
Response (Camden and Islington NHS Trust): • The trust amended its action plan template. • The trust revised its guidance for authors writing recommendations and action plans. • An action row was added to the action … (AI summary)
Responded
Brian Gillard
Concerns: The coroner identified insufficient handover procedures regarding a patient's need for ambulatory oxygen during transfer between hospital departments. This led to ward staff being unaware of the patient's oxygen requirements, and portable oxygen not being used when he went to the toilet.
Overdue
Michael Hanlon
Concerns: The coroner noted concerns regarding the efficacy of the boat's entry system for crew returning after 10 pm. There were also issues with the recording and monitoring of crew working hours, which may have led to tiredness from additional shifts.
Response (Pluteus Limited): • A new keyless entry system, which issues personal access codes to crew members, was installed in summer 2015. • The Captain will issue a Standing Order in the week … (AI summary)
Responded
Harry Pryal
Concerns: The coroner noted the absence of documented medical advice provided by WWL to the Lakeside Unit, which impacts continuity of treatment. There were also differing interpretations of the Service Agreement between SBP and WWL, and no scheduled liaison meetings had taken place as required by the agreement.
Response (Department of Health): • The Academy of Medical Royal Colleges (AoMRC) has produced Standards for the clinical structure and content of patient records. • The Health and Social Care Information Centre (HSCIC) is … (AI summary)
Response (Wigan Borough CCG): • The CCG wrote to SBP stating that SBP should have a service agreement for the provision of physiotherapy and occupational therapy. • SBP confirmed that all requests for physiotherapy … (AI summary)
Response (5 Borough Partnership NHS Trust): • The Trust developed a standardised proforma for use during transfers between trusts and issued a directive requiring clinicians to fully record clinical advice, including the name, grade, and contact … (AI summary)
Response (Wrightington Wigan and Leigh NHS Trust): • The Trust updated its Standing Financial Instructions (SFIs) to include a new sign-off process for Service Agreements, which was approved at Trust Board level. • Discussions were held, and … (AI summary)
Responded
Alan Tear
Concerns: Post-operative instructions were not followed by nursing staff, and rising EWS observations were not reported to medical staff. The Interventional Radiology team lacked understanding of nursing observations, highlighting a need for improved inter-team communication.
Response (University Hospitals of Leicester NHS Trust): • The matron met with nursing staff to reinforce awareness of required observation frequency. • The Trust committed to continuous teaching sessions for staff on interventional radiology for surgical patients … (AI summary)
Responded
Matthew Crowley
Concerns: The coroner identified delays in A&E assessment due to staffing and an inoperable protocol. Concerns also included on-call consultants lacking updated patient deterioration information, leading to delayed decisions and issues with transfer communication.
Overdue
Freda Weston
Concerns: Insufficient doctor and nurse staffing led to significant delays in antibiotic administration and patient review. The report also notes issues with adherence to escalation guidelines, clarity of pharmacy medication details, and immediate shredding of handover sheets.
Response (Weston): • The Trust stated it would not alter its current practice regarding Septrin usage or implement a period of observation after starting Septrin, citing clinical reasoning. • The Trust clarified … (AI summary)
Responded
Martha Davies
Concerns: The coroner identified serious communication failings and an over-reliance on agency and junior staff to make decisions. Concerns were also raised about the lack of a prompt response to the patient's deteriorating state and documentation issues.
Overdue
Michaela Thompson
Concerns: The coroner identified inadequate documentation of multi-disciplinary team meetings regarding attendees, decisions, and outcomes. Additionally, a significant phone call from Michaela to the service was not recorded, nor was it immediately communicated to her community mental health nurse.
Response (Leeds and York NHS Trust): • The trust committed to ensuring clear documentation of attendees, outcomes, and decisions at multi-disciplinary team meetings. • The trust agreed that the facility to record calls coming into clinical … (AI summary)
Responded
Winifred Elliott
Concerns: The coroner noted that removing resident transfer information from display in rooms made it harder for staff to access, potentially leading to inappropriate transfers and injuries. There were concerns about the CQC's role in advising homes to implement and display such information.
Response (CQC): • CQC reviewed its inspection reports and clarified its position on displaying information in bedrooms, noting that privacy and confidentiality must be considered. • CQC confirmed its inspection methodology assesses … (AI summary)
Overdue
David Cooper
Concerns: Concerns include inadequate handover between wards regarding falls risk, incomplete nursing notes, and deficiencies in the system for allocating one-to-one care for high-risk patients.
Response: • The Health Board established a Falls Management Group in September 2015, which reviewed policies and training requirements and introduced National Patient Safety Agency Risk Assessments. • The Falls Management … (AI summary)
Overdue
Lita Serkes
Concerns: Concerns noted incomplete and inaccurate medical record-keeping, delays in transferring a patient for emergency stroke care, and delayed review of critical blood results. An unconnected pain relief device also meant analgesia was not delivered.
Response (Barts Health NHS Trust): • The requirement for accurate patient observation recording was reiterated to nursing staff, and specific training was provided. • The Trust is reviewing its hospital policy for stroke management and … (AI summary)
Responded
Jane Stables
Concerns: The coroner identified ineffective communication between nurses and the general practitioner regarding ongoing significant pain levels that were impeding care provided.
Response (Allied Healthcare): • Allied Healthcare introduced a new system for carers to report significant changes, supported by Lead Nurses, and amended care plan documents to include referral flagging tools. • A care … (AI summary)
Response (RDASH): • A meeting was held with relevant District Nurses and their Line Managers to discuss the case and identify learning, including the need for direct professional dialogue on pain management. … (AI summary)
Responded
John Atkinson
Concerns: The coroner identified gaps in updating patient risk assessments, managing patients when care co-ordinators depart, and effective communication among mental health professionals. Difficulties for psychiatrists in accessing Home Treatment Team Services were also noted.
Response (Rotherham Doncaster and South Humber NHS Trust): • The Trust commissioned tailored STORM training for the Intensive Community Therapies Team and implemented weekly audits of risk reviews. • The Trust implemented immediate actions to reduce risk for … (AI summary)
Responded
David Moran
Concerns: The coroner noted imprecise guidance for categorising referral urgency, specifically the lack of a default to urgent when screening was not possible or in cases of doubt. There were also concerns regarding ineffective communication between administrative and clinical staff.
Response (5 Borough Partnership NHS trust): • Standard Operating Procedures (SOPs) have been developed and implemented for the Assessment Team, establishing a default to urgent face-to-face assessment within 72 hours for uncertain referrals. • The Assessment … (AI summary)
Responded
Patrick Steer
Concerns: Concerns were raised regarding inadequate communication between Surgical and Coronary Care teams for patients under shared care, and the absence of a clear Trust policy to manage this interaction.
Responded
Robert Cardwell
Concerns: The coroner identified unreliable processes for relaying patient messages to the Multi-Disciplinary Team (MDT), leading to inappropriate discharge. Further concerns included the MDT not discussing referred patients and inadequate record-keeping during meetings.
Overdue
Rayan Ahmed
Concerns: The coroner noted that nurses in the special care unit cover babies during breaks without sufficient prior knowledge, suggesting that shift handovers or break-time handovers should include all babies a nurse might be responsible for.
Overdue
Mohammad Ashraf
Concerns: The coroner identified inadequate and delayed allergy care plans for pupils, ineffective communication between the school and caterer, and an unsafe allergy identification system. Crucially, the Local Authority did not communicate safety recommendations to the school.
Response (Birmingham Community Healthcare): • The Trust worked with Al-Hijrah school to provide a full response. • The Trust's comments were incorporated into the school's letter. • The Trust responded to concern no.2 within … (AI summary)
Responded
Philip Powell
Concerns: The coroner identified delays in ordering Debrisoft for wound management and poor communication, alongside confusing systems, regarding its procurement process and overall responsibility.
Response (Dudley Group NHS Trust): • The Trust confirmed it had developed an action plan in response to the concerns. • The action plan details steps taken, target dates, and responsible officers. • The Trust … (AI summary)
Responded
Doreen Wilkins
Concerns: The coroner raised concerns that carer rotas do not always allow for travel time, which may lead to late arrivals for time-critical visits or carers cutting short visits, resulting in clients not receiving their assessed duration of care.
Response (Comfort Call): • The organisation stated it would introduce new technology to track care worker activity in real time and alert coordinators if a critical call is missed. • An agreement was … (AI summary)
Responded
Catherine Kennedy
Concerns: The coroner identified that robust measures are not consistently in place to reduce miscommunication between ward staff and on-call doctors. This includes the absence of a consistent communication paradigm (such as SBAR) for telephone conversations.
Response (Pennine Care NHS Trust): • The Trust confirmed that the SBAR(D) communication tool is taught within several training courses, including Intermediate Life Support and Clinical Risk Formulation Training. • The Trust stated that A5 … (AI summary)
Response (Greater Manchester Mental Health NHS Foundation Trust): • The Trust updated and attached an action plan addressing the concerns raised in the Regulation 28 Report. • Standard Operating Procedures for Community Mental Health Services have been revised … (AI summary)
Responded
Derek Smith
Concerns: The coroner noted insufficient communication between the District Nursing team, family members, and carers, alongside issues with the availability of nursing records. This limited opportunities for timely interventions and decision-making regarding Mr Smith's treatment.
Overdue
Bradley Morgan
Concerns: The coroner noted a communication breakdown between mental health teams led to a patient not receiving follow-up care. Concerns were raised that high staff caseloads and chronic underfunding of mental health services continue to pose a risk.
Response (NHS England): • The Clinical Commissioning Group (CCG) provided additional investment in mental health services in 2017/18 and 2018/19. • A Quality Improvement Board was established, and a governance framework was put … (AI summary)
Response (NHS Birmingham and Solihull ICB): • The CCG committed to reviewing its serious incident reporting policy and operational processes to strengthen quality assurance. • It stated it would work with partners to address staff recruitment … (AI summary)
Responded
Mary Johnson
Concerns: The coroner noted a lack of communication among staff regarding pre-operative patient feeding and medication adherence, alongside concerns that porter availability affected the hospital's capacity to perform operations.
Response (Wye Valley NHS Trust): • The use of thromboprophylaxis to surgery, including the time period for withholding, has been relaunched and clarified to all pertinent staff. • All speciality-specific thromboprophylaxis guidelines are currently under … (AI summary)
Responded
Gail Bailey
Concerns: The coroner identified concerns regarding an apparent breakdown in communication for emergency admissions, noting that despite pre-alert calls, hospital clinicians appeared unprepared and specialist teams were not forewarned of the patient's arrival.
Overdue
Calary Davis
Concerns: An incomplete action plan from a root cause analysis, risks from a maternity service merger, and a culture of not performing specific procedures at night were noted. Additional concerns included insufficient staffing levels and leadership gaps.
Response: • A corrective action plan for improvement was developed and updated, with monitoring through Improvement and Quality Safety Boards. • Reviews of 43 cases and all neonatal and stillbirths from … (AI summary)
Responded
Tamsin Grundy
Concerns: The coroner noted Miss Grundy's distress from seeing over 25 members of the Crisis Resolution Home Treatment Team, requiring her to repeatedly explain her difficulties. There was no definitive, timed action or named person responsible for addressing this issue, despite it being raised.
Response (Norfolk Suffolk NHS Trust): • The Crisis Resolution and Home Treatment (CRHT) team is using a national 39 fidelity scale to reflect on current practices and identify areas for improvement. • The team is … (AI summary)
Responded
Muhammed Haleem
Concerns: Information on the NWAS system for paramedic guidance was outdated, and there was a lack of communication between community paediatric teams and emergency services regarding DNA-CPR orders for children.
Response (North West Ambulance Service NHS Trust): • The Trust accepted the need to develop and implement a system for identifying outdated or review-requiring DNA-CPR markers. • The Regulation 28 report prompted internal and commissioner discussions regarding … (AI summary)
Response (Pennine Care NHS Trust): • Alerts have been placed on the NWAS system for all children with current advance care plans. • Archived paper notes for children with palliative care needs will be reviewed … (AI summary)
Responded
Mary Jones
Concerns: The coroner raised concerns about the out-of-hours transfer of a frail patient causing delayed risk assessment. Issues included poor clinical documentation, lost IT records, and a lack of dietician referrals or fluid chart review.
Overdue
Amy Allan
Concerns: Concerns were raised about a lack of information sharing between hospital departments, an absence of clear post-operative plans for extubation and ECMO, and a poorly executed clinical handover. These issues contributed to a delay in commencing ECMO therapy.
Response (Great Ormond Street Hospital for Children): • The Trust amended multi-disciplinary team (MDT) Terms of Reference to mandate attendance of relevant specialists and ensure effective dissemination of meeting outcomes, supported by new electronic patient record features. … (AI summary)
Responded
David Potts
Concerns: The coroner identified concerns regarding the untimely administration of Beriplex, a lack of follow-up to ensure it had been given despite an extended bleed, and a lack of clarity regarding its non-administration and the patient's location.
Overdue
Karis Braithwaite
Concerns: The Trust lacked an effective process for critical risk information from first responders (paramedics and police) to be documented and made available to the mental health assessment team, leading to insufficient information for assessment.
Overdue
Rebecca Hursey
Concerns: The coroner raised concerns regarding the need for clinical record-led handovers focusing on risk, verbal communication of increased suicidal risk, timely and prioritised alternative placements for high-risk patients, and inter-unit sharing of complex cases.
Overdue
Sarah Young
Concerns: The coroner noted a lack of medical team review despite referral and conflicting views on responsibility between medical and ITU teams. There was a significant delay in obtaining a neurological opinion, which hindered early diagnosis, and issues with the standard neurology referral system.
Overdue
Select committee recommendations(6)
#132 —
Recommendation: The FCA and PRA must review how their supervisory staff are deployed to ensure greater consistency in the staffing of supervisory teams and to address reports of frequent rotation amongst supervisors. A lack of proportionality in regulation and supervision
Response attribution not verified
#126 —
Recommendation: However, low aggregate turnover does not necessarily guarantee continuity in the important supervisory function. Indeed, David Bailey, Executive Director for Prudential Policy at the PRA, noted that staff rotations are inherent to the PRA’s supervisory approach: “We need the supervisors …
Response attribution not verified
#123 —
Recommendation: We received evidence that frequent personnel changes in a firm’s supervisory team reduce the pace of supervision. Aon told us that: “the high turnover of the FCA means supervisory teams are frequently changing; new supervisors are having to familiarise themselves …
Response attribution not verified
#122 —
Recommendation: Several witnesses cited the frequent rotation of staff in supervisory teams as a concern. TheCityUK told us that: “Poor understanding of firms’ business models is exacerbated by regular churn in supervisory teams.” 196 We received evidence that frequent rotation requires …
Response attribution not verified
#114 —
Recommendation: Witnesses suggested that there were inconsistencies in the quality of supervision and an overdependence on rigid and inefficient supervisory processes, increasing the demands placed on firms. Witnesses told us that the frequent rotation in supervisory teams can disrupt the continuity …
Response attribution not verified
#18 —
Recommendation: HMPPS assured us that as the programme to reunify probation services was on scheduled to complete in June 2021. It told us that it was consistently monitoring the caseloads of probations officers but that these remain high. HMPPS told us …
Response attribution not verified
HSSIB safety recommendations(5)
Detection of retained vaginal swabs and tampons following childbirth
It would be beneficial for trusts to review their planned handovers and for all staff groups to have adequate time in their shift to conduct handover tasks and participate in team briefings. Practices at the end of tasks
Safety Observation
Patients at risk of self-harm: continuous observation
Is there a clear and comprehensive process for handing over a patient’s care to staff on the receiving ward?
Learning Prompt
Timely detection and treatment of cauda equina syndrome
The regional specialist spinal centre described in this report has worked with the electronic referral system manufacturer to ensure alerts are received by neurosurgical doctors. This has included doctors having a single ‘baton’ telephone that receives the alert, with the …
Safety Action
Patients at risk of self-harm: continuous observation
Is there a mechanism for regular communication and review of a patient’s risk of self-harm and need for observation?
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there a shared understanding of the different roles and responsibilities of mental and physical healthcare staff in caring for a patient, including checking their personal belongings for items that could be used to self-harm. Are the different roles and …
Learning Prompt
NCEPOD recommendations(1)
CQC inspection actions(15)
North Middlesex University Hospital
The services should improve communication with staff regarding staffing decisions.
Should Do
Holly House Residential Care Home
The provider must ensure that staffing rotas accurately demonstrate staffing numbers, reflect all shifts worked, and reconcile with payroll records and actual hours worked.
Must Do
Fleetwood Hospital
The services should consider how communication with all staff can be improved so that they are kept fully informed of key issues affecting their service and are more engaged.
Should Do
Affinity Trust Specialist Support Division North
People's needs and any changes in their care and support was not always shared with staff.
Must Do
Fleetwood Hospital
The services should consider how communication with all staff can be improved so that they are kept fully informed of key issues affecting their service and are more engaged.
Should Do
TerraBlu Homecare
Other people and relatives did not have the same experiences. One person told us, "I asked for a 08.00am call and at first I was getting calls at 07.00 am or 07.30 am, it's better now but they never call …
Should Do
Shining Star Home Care Limited
Improvements were required for staff's schedules, so the provider could be assured staff were attending calls in line with the person's time preference.
Should Do
Prospects for People with Learning Disabilities - 3 Norwich Road
Staff meetings were not as regular as they would like them to be. It was difficult to arrange a time when most of the staff would be able to attend. There was still a poor turn out at the meetings …
Should Do
London Hair Transplant Clinic
The service should ensure that staff meetings are well attended and the minutes contains sufficient detail to provide a clear understanding of what was discussed.
Should Do
Care Outlook (Bellerophon House)
The regional manager added this to the action plan for the service to ensure any changes to staff rotas are made through direct communication with the staff member rather than changes to the rota in the electronic system used by …
Should Do
Bromsgrove
The service should ensure staff meeting minutes have sufficient detail for staff who do not attend the meeting to understand what is discussed.(Regulation18).
Should Do
Verve Health
The service should ensure that regular full staff meetings, staff multi-disciplinary meetings and handovers occur in order to discuss service user needs, share relevant key information and share learning or areas for improvement.
Should Do
Monaveen
The provider must ensure governance systems sustain improvements and address failures in communication and engagement with people and staff.
Must Do
St Clare's Hospice
The provider should review the on call arrangements for the hospice and ensure there is clarity in regard to which managers are on call.
Should Do
Age Concern Home Care Central Manchester
We recommend that the registered manager has improved oversight of the electronic call monitoring system and processes to ensure people receive care at the right time.
Should Do
HMICFRS recommendations(2)
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:- review its current arrangements for managing the working time of staff who …
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
ICIBI immigration recommendations(2)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and …
An inspection of Border Force operations at Stansted Airport
Recommendation 4 Produce an improvement plan for internal communications at Stansted that reduces the reliance on email, ensures ‘top down’ messages reach and are understood by all affected staff, and …
PPO death in custody recommendations(2)
The Head of Healthcare
The Head of Healthcare should review the process of sharing information between one shift and the next.
The Governor of Stafford
The Governor of Stafford should ensure that officers taking over bedwatch duties read the bedwatch log at the start of their shift, so they are aware of any ongoing issues.
IOPC learning recommendations(10)
Care and attention for man whilst detained in custody – Thames Valley …
The IOPC recommends that Thames Valley Police ensures arrangements are in place for all custody officers, staff and HCPs to receive information about detainees when their shift starts. This follows an investigation into the death of a man at a …
Recommendations - Sussex Police, November 2019
There was a lengthy delay in resourcing a request for a welfare check that was graded Grade 2 (expected response time 1 hour). There were resourcing issues that led to this delay, the incident log provided very little information about …
Recommendations - Sussex Police, November 2019
There was a lengthy delay in resourcing a request for a welfare check that was graded Grade 2 (expected response time 1 hour). There were resourcing issues that led to this delay, the incident log provided very little information about …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police implement a policy to ensure that there is consistency in how LPU sergeants inform the control room staff about availability of their staff to be deployed. Some sergeants provide the control room with a …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police clarify and/or implement/formalise an escalation process when there are outstanding matters to be resourced. Due to the lack of policy, some staff members inform their supervisors whilst other do not. This incident was left …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police implement a policy to ensure a clean handover from one LPU shift to the next takes place. No handovers were recorded at shift change times. The IOPC is aware that Derbyshire have implemented some …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police introduce a policy and guidance for the management of the different lists of jobs, so supervisors are aware of their responsibilities in relation to them. The supervisors within the LPU were not aware of …
Recommendations - Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police standardise terminology within the local policing unit (LPU) and the control room for the lists of jobs to be managed and dealt with to avoid any confusion as to who is responsible for what. …
Recommendations - Metropolitan Police Service, June 2024
The IOPC recommends that the MPS should increase awareness amongst officers regarding the Resource Management Policy, particularly concerning the booking on and off of colleagues other than themselves through the CARMS system. Training should be put in place to ensure …
Recommendation - Metropolitan Police Service, October 2024
The IOPC recommends that the Metropolitan Police Service (MPS) should put a process in place to re-allocate workloads where there is confirmation of an investigator’s absence from their role for a period of time either on leave, secondment or for …
IMB annual reports(3)
Ford (2021)
HMP Ford experienced a challenging year marked by Covid-19 restrictions, which the prison successfully managed, limiting outbreaks and reducing violence. Significant accommodation changes occurred with the condemnation of B wing and the introduction of new pods, which, despite initial issues, led to a reduced but more modern estate. The Board commended the prison's efforts in restoring and increasing external employment opportunities for prisoners post-restrictions, contributing positively to resettlement goals.
PRISON
Key concerns
Buckley Hall (2025)
HMP Buckley Hall, a Category C training prison, has a population of 460 men. The Board noted significant improvements in healthcare and positive engagement in DARS and family visits, alongside strong staff dedication. However, chronic staff shortages severely impact the regime, leading to frequent lockdowns and cancelled activities. Key concerns include an ineffective maintenance contract, persistent property issues during transfers, and the detrimental impact of the birthday parcel policy. The Board also highlighted tired accommodation, hygiene issues, and a high number of self-harm incidents.
PRISON
Key concerns
Bronzefield (2025)
HMP/YOI Bronzefield, a women's local and YOI prison, reported a population of 506 and a CNA of 5271. While some progress was noted in leadership and property management, the report highlights significant concerns regarding healthcare delivery, staffing pressures, and the impact of roll-counts on the regime. Mental health services remain strained, and issues with food provision, complaint handling, and resettlement support persist, many of which were repeated from previous years.
PRISON
Key concerns
IMB individual recommendations(43)
Coldingley (2023)
Changes which affect prisoners have not always been well communicated within Coldingley. This creates an atmosphere of confusion and at times hostility. What can the Governor do to improve the methods of communication to ensure all prisoners understand the changes and why they are considered necessary?
Governor / Director
Wealstun (2020)
Ensure that post is collected from the post room daily by the wing staff (see paragraph 7.2.4).
Governor / Director
Ford (2021)
Communication has continued to be a problem. During lockdown you held regular forums attended by a representative from each corridor but the information given out did not seem to reach the other prisoners in spite of the fact that the forums were each followed up by a notice to the community. Prisoners also reported that communication with staff, particularly the …
Governor / Director
Altcourse (2022)
Recruitment of staff has to be a priority to minimise the redeployment of staff from designated roles to cover for vacancies elsewhere.
Governor / Director
Ranby (2023)
More staff interaction, better information for prisoners to know who their offender manager and personal offender manager are.
Governor / Director
Huntercombe (2023)
How will the Governor work with staff to ensure that the roll call is accurate, so that prisoners are not disadvantaged by not being able to attend work, education or healthcare?
Governor / Director
Fosse Way (2025)
Communications could, in our view, be better with various committees/meetings cancelled or changed at short notice without the IMB being informed. This has resulted in situations where we have arrived at a meeting and it has not taken place.
Governor / Director
Berwyn (2022)
The Board is concerned that the establishment is regularly impacted by staffing shortages, causing restricted regimes and impacting upon important initiatives such as key work.
HMPPS
Oakwood (2021)
The Director to review the range of alternative communication options in addition to communication via the kiosks on the wings. Prisoners have commented that, at times, they were not always aware of the arrangements for Purple Visits and exercise times, which appears to be linked to the lack of time available to the prisoners to use the kiosk during lockdown. …
Governor / Director
Implemented
Lancaster Farms (2021)
To review the suitability and implications of making transfers between prisons on Fridays (4.1.2).
HMPPS
Noted
Wymott (2022)
On a number of occasions, poor communication between functional areas has led to conflicting information being provided to both prisoners and Board members. What strategies does the Governor have to improve this?
Governor / Director
Standford Hill (2022)
It appears to the Board that communications between GFSL and the prison needs to improve radically in order to ensure that those parts of the prison dependent on the work of GFSL are enabled to run smoothly.
HMPPS
Send (2023)
The Board is concerned about the impact of prison staffing issues on delivering regular keywork as intended in the OMiC model.
Governor / Director
Kirkham (2023)
The IMB recommends that there should be a strategy for when activities are curtailed, due to redeployment of staff, to deal with absences/emergencies.
Governor / Director
Five Wells (2023)
The Board’s rota reports have highlighted that inconsistencies and frequent changes in regime have undermined the running of the houseblocks, with some staff feeling unsupported and lacking the confidence to enforce where necessary. What action will be taken to remedy this?
Governor / Director
Feltham (2023)
Please could more information be made available regarding TOoR - e.g. inclusion of data in Daily Briefing and flagging all children with less than two hours TOoR?
Governor / Director
Deerbolt (2023)
The Board believes that HMPPS needs to improve the property-handling process and access to the facilities’ list, which sets out when clothing parcels can be applied for and the process for an application.
HMPPS
Deerbolt (2023)
We recommend that the prison makes these documents readily available on each wing.
Governor / Director
Swaleside (2024)
With the staffing ratio now up, due in part to the temporary closure of two wings, the Board now expects the low level of keywork to be addressed.
Governor / Director
Sudbury (2024)
The Board has continued to note that some prisoners perceive there to be inconsistencies between the OMU staff, in terms of processing ROTL applications, but also acknowledges the recent changes to the systems in use and the appointment of additional management in the area. An ongoing concern raised by prisoners is the lack of regular communication between them and the …
Governor / Director
Styal (2024)
What progress is being made in reducing non-attendance at healthcare, education and activities, caused by scheduling conflicts.
Governor / Director
Risley (2024)
Staff absences over summer months continue to hinder the regime, particularly in access to workshops. Does the organisation plan to evaluate its staffing provision at peak times of leave throughout the year?
HMPPS
In Progress
High Down (2024)
The Governor should improve communication with prisoners, particularly with regards to regime changes.
Governor / Director
In Progress
Bullingdon (2024)
What steps will the Governor take to address the significant decrease in key working?
Governor / Director
Bronzefield (2024)
What plans does Sodexo have to address the significant impact of staff shortages on the provision of services in the prison? (3.1, 5.3)
Other
Bronzefield (2024)
Roll count has frequently been late, which has had a negative impact on the regime and security. How will the prison ensure that roll count returns to being accurate and timely? (4.6)
Governor / Director
Thameside (2025)
While the Board acknowledges the measures taken to clear the backlog of court cases, this has resulted in vans regularly arriving at the prison after the lock out time of 8.00 pm. (see table 1, Annexe C). What actions will the Prison Service take in conjunction with the Prisoner Escort and Custody Service to minimise this?
HMPPS
Noted
Morton Hall (2022)
tightening up and/or amending the processes for roll reconciliation so that prisoners can take part in planned activities on time (see paragraph 6.5.4).
Governor / Director
Channings Wood (2022)
What can be done to ensure that men arriving at Channings Wood late on a Friday receive the same level of support during the reception process as those arriving during the working week?
Governor / Director
Channings Wood (2022)
Prisoners arriving late on a Friday report a significantly poorer induction experience than those arriving during the core working week. What will the Prison Service do to minimise the number of routine planned transfers taking place on a Friday?
HMPPS
Feltham (2023)
Could someone identify which spaces are available for outreach meetings. e.g. out-of-use corner rooms, etc?
Governor / Director
Drake Hall (2023)
The Board would like access to PSIs to be improved for women in the open unit and the CSU.
Governor / Director
Bure (2024)
The Board remains concerned that education and workshop classes are underused, due to conflicting healthcare appointments and activities.
Governor / Director
Buckley Hall (2024)
Concerns have been raised about the restrictive timing of the social video calls, which impact on a family’s ability to utilise them.
Governor / Director
Bronzefield (2024)
What plans does the prison have to prioritise prisoner/key worker meetings for those prisoners who have been identified as most likely to benefit from them? (5.3)
Governor / Director
Swaleside (2025)
Staff and prisoner relationships have been damaged by the huge influx of inexperienced staff. Will the Governor reassure the Board that the recent recovery in key work sessions from a low base will be matched with quality assurance?
Governor / Director
Styal (2025)
What plans are in place to allow the current limited supervision of the houses to be extended, to enable staff to respond to prisoner requests and listen to their concerns?
Governor / Director
Ashfield (2025)
The impact of key work reporting, providing escort staff in hospital and occasional redeployment to other Serco prisons has meant fewer wing officers available, all of which has resulted in low staff morale. What steps are being taken to relieve these pressures?
Governor / Director
Wetherby (2021)
The lack of permanence within the senior management team is of great concern to the Board. Is the Governor able to offer reassurance to the Board that some level of stability will take place? Barnardo’s advocacy has an important role to play in supporting the young people. They hear of Barnardo’s role, along with that of many others, during the …
Governor / Director
Cookham Wood (2023)
What urgent steps will Cookham Wood take to ensure a stable and predictable regime for the boys, with improved time out of cell and minimal last-minute changes and cancellations?
Governor / Director
Isis (2024)
What alternative methods are there for bringing urgent but not emergency issues to the attention of officers?
Governor / Director
Whitemoor (2025)
Will the Governor take action to prevent interruptions to key functions such as visits management due to lack of resilience in staffing?
Governor / Director
Bure (2025)
Why are prison officers sent on ‘detached duties’ (deployed at prisons away from their usual base) when it leaves Bure with staff shortages, especially when most days several staff are required to be out of the prison for planned and unplanned escorts to hospital? Staff shortages in the establishment are impacted further by bed watches.
HMPPS
In Progress
Health investigations(12)
Independent investigation: Prodip Debnath, Mile End (2010) — Rec Five
It is recommended that the Trust devises a system whereby key information about patients is communicated to all staff on duty at any given time and that this follows a standardised, structured and documented process.
london
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 18
The Trust should review the adequacy of the length of time and quality of ward handovers to ensure that sufficient time is made available for effective clinical communication and teaching
london
Independent investigation: Camille Remy (pregnant), Hackney (2006) — Rec R23
BEH NHS trust should ensure that staff required to prepare reports or give evidence before a MHRT are informed immediately of any application to the MHRT and of any date fixed for a MHRT hearing so they can prepare for the hearing.
london
Independent investigation: Adel Makar, Westcliff on Sea (2006) — Rec 9
The BL Trust sets up a system that documents the arrangements when a named Nurse is absent and ensures that the patient is aware of these.
east_of_england
An independent inquiry into the care and treatment of Ms … — Rec 7
Medical leave to be better co-ordinated and a standardised system of handover of care during these periods to be developed in the CMHT, with consultants making better use of the leave folder in the shared drive.
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xiv)
The Trust should devise and operate a definitive system of liaison between psychiatrists and depot clinic nurses for both Enhanced and Standard CPA cases.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.h
Change of care co-ordinator – enhanced CPA The policy should explicitly deal with the circumstances where there is to be a change of care co-ordinator for a person on enhanced CPA. There should preferably be a face-to-face transfer meeting involving a CPA review. The policy should take into account that …
london
Independent investigation: Justin Skrebowski, Abingdon (2015) — Rec 4
A certain level of staff turnover is normal and unavoidable, but very frequent changes are disruptive particularly for someone with complex mental health needs. Change should be kept to a minimum, as Trust policy states, but where changes occur, a review of the Care Plan and risks should always be …
south_east
Independent investigation: Adel Makar, Westcliff on Sea (2006) — Rec 18
The out of hours duty rota for cover to the Orchard Unit should be part of the general duty rota for the psychiatric services within the BL Trust, both now and in the future. The medical staff of the unit should participate in the on call duty rota for the …
east_of_england
Independent investigation into the care and treatment of Mr D … — Rec 5
The Crisis Resolution and Home Treatment Team (CRHTT) should review its admission process to ensure urgent referrals can be accepted and managed during handover periods.
Cambridgeshire and Peterborough NHS Foundation Trust
east_of_england
Assurance Review: Trust recommendations — Rec 7
Risk registers at service, care group and Trust level The challenges currently being faced by the Urology service should be reviewed to determine whether the risks are sufficient to warrant inclusion on the service, care group or Corporate Risk Register (CRR) or the Board Assurance Framework (BAF); this includes the …
north_west
Assurance Review: Trust recommendations — Rec 44
Patient handover Handover of patients between Consultants should include: • A formal handover arrangement between Consultants for out of hours cover. • A handover for patients who are transferred between Consultants.
north_west
Article 2 learning points(1)
Detention investigations(3)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 8
Group 4 reviews its roll count procedures to ensure they are accurate and efficiently carried out.
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 the Disturbance and Fire at Yarl's Wood Removal … — Rec 48
GSL reviews its shift systems with a view to ensuring consistency of operation and that staff are able to perform at their optimum throughout their duty.
Immigration Detention
LGO / SPSO decisions(5)
24-012-733 — Leicester City Council
Summary: The Council was at fault for its handling of Mrs X’s school transport application and subsequent appeal. It gave Mrs X inaccurate information, and its appeal response lacked the detail required by the statutory guidance. This caused Mrs X significant distress, uncertainty, time and trouble. The Council has agreed …
LGO (Local Government & …
Education
Upheld
Jun 2025
201600725 — Lothian NHS Board - Acute Division
Miss C complained about the care and treatment she received at St John's Hospital. She had been diagnosed with skin cancer and had an operation in the hospital to remove the cancer. She said that, after the operation, the anaesthetist refused to give her further pain relief without having seen …
SPSO (Scottish Public Se…
Health
Partly Upheld
Apr 2017
22-004-483 — Wokingham Borough Council
Summary: We will not investigate this complaint about the Council changing the hours of operation of one of its offices. There is insufficient evidence of fault which would warrant an investigation.
LGO (Local Government & …
Environment And Regulation
Jul 2022
22-004-845 — Coventry City Council
Summary: We will not investigate this complaint about the Council carrying out non-essential work outside the complainant’s house on the day of their late mother’s funeral. There is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Transport And Highways
Aug 2022
22-006-242 — Spelthorne Borough Council
Summary: We will not investigate Miss X’s complaint about the Council’s decision to change where she should store her waste bins. We cannot make findings on the land ownership and legal issues at the core of the complaint so cannot achieve a different outcome from investigating or get her the …
LGO (Local Government & …
Environment And Regulation
Aug 2022
Domestic Homicide Reviews(5)
Middlesbrough — recommendation 17.21
Guidance to be re-issued to staff in relation to caretaking cases and the importance of good communication between staff and the expectations around enforcement when caseholders are unavailable/on leave. In addition to the timeliness of requesting caretaking. (Caretaking means someone else has to look after the case in the absence …
National Probation Service
National Probation Service
Harrow — recommendation 2
Discuss in Leaders Meetings ward meetings and handovers.
Ealing Hospital
Ealing Hospital NHS Trust
Nottingham — recommendation Equation 3
Caseworkers to be reminded/encouraged to cover work on each other’s cases when the caseworker is not available to ensure no unnecessary gaps in service delivery.
Equation
Oxford — recommendation 14
Thames Valley Police to put in place an archive system for storage of handover documents between shift supervisors.
Thames Valley Police
Thames Valley Police
Preston — recommendation 2
Develop short code/key words to alert office/staff member of an incident. Universal key words to be agreed upon.
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