Staff suitability and fitness
Failure to ensure that employed staff possess good character, necessary qualifications, skills, experience, and physical and mental fitness for their roles.
Source spread
Where this theme appears
This theme appears across 22 independent accountability sources, so the source mix matters as much as the headline total.
114 inquiry recs
39 PFD reports
74 committee recs
8 HSSIB recs
215 CQC actions
39 HMICFRS recs
1 ICIBI rec
4 PPO recs
4 IOPC recs
70 IMB recs
5 Scottish FAIs
1 Article 2 learning point
9 detention investigation recs
42 DHR recs
3 PHSO decisions
46 LGO/SPSO decisions
2 CJINI reports
2 DSA service inquiries
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(114)— showing 50 strongest matches
22 — Service after retirement age
Recommendation: The extension of service after retirement age should be most carefully considered in each individual case and regularly reviewed.
Unknown
38 — Suitable calibre and training of managers
Recommendation: Hospital managers shall be of a suitable background and calibre for the role expected of them, provided with all necessary training (including continued education) and themselves regularly appraised for the quality of their performance.
Unknown
35 — Clinical experience for managers
Recommendation: No clinician shall be appointed to a position of managerial authority in a hospital without having relevant clinical experience for the position.
Unknown
25 — Joint disciplinary procedure
Recommendation: There shall be a joint procedure for disciplinary action against an individual perceived to be failing. It shall contain provision for immediate suspension from patient care as a minimum, irrespective of academic requirements and positions.
Unknown
24 — Joint job description for clinical academics
Recommendation: A single job description for clinical academics shall be drawn up jointly to represent a fair and realistic expectation of the work envisaged by both parties.
Unknown
22 — Fair representation in clinical academic posts
Recommendation: The appointment of clinical academics shall be approached with fair representation on each side reflecting the proposed split between clinical and academic sessions.
Unknown
173 — Child care expertise not for all social workers
Recommendation: It should be recognised that the area of child abuse in general and child sexual abuse in particular is an area of expertise into which not all members of the profession should necessarily enter (19.9).
Unknown
98 — Selection criteria for OIMs
Recommendation: The operator’s criteria for selection of OIMs, and in particular their command ability, should form part of its SMS (para 20.59).
Unknown
94 — Standby vessel crew age and fitness
Recommendation: The proposals in the amended code as to age limit, medical examination and certification of fitness of members of the crew of standby vessels; and as to their periods of duty are endorsed (paras 20.51-52).
Unknown
41 — Control Room manning and qualification
Recommendation: The Control Room should at all times be in the charge of a person trained and qualified to undertake the work of Control Room operator. The Control Room should be manned at all times (para 18.35).
Unknown
7 — Adopt hours of work rules as guidelines for Class V vessels
Recommendation: The statutory requirements in the Merchant Shipping (Safe Manning, Hours of Work and Watchkeeping) Regulations 1997 should be adopted by owners of Class V passenger vessels as guidelines. They should also note the requirements of STCW95, Section A-VIII/1 regarding fitness …
Unknown
6 — Monitor crew hours for fatigue
Recommendation: Owners and operators should monitor and review the hours of work of their employees in order to ensure that they are not affected by fatigue.
Unknown
4 — Carry out random testing
Recommendation: Owners and operators should in fact carry out random testing because of its deterrent effect.
Unknown
3 — Random testing in contracts
Recommendation: Such contracts should permit random testing for alcohol and drugs, with appropriate penalties if levels of alcohol or drugs in excess of those permitted by the contract (if any) are found or in the case of a refusal to supply …
Unknown
2 — Operator alcohol and drugs policies
Recommendation: Owners and operators of all vessels should have an active alcohol and drugs policy and include provisions in their contracts of employment relating to permitted levels of alcohol and drugs, if any.
Unknown
FP79 — Recommendation 79
Recommendation: Absence of authorisation under the Act should not be taken as disqualifying a witness from being treated as an expert in relation to fingerprint evidence. The witness should be prepared to demonstrate his or her expert status on ordinary common …
No response yet
FP78 — Recommendation 78
Recommendation: The system of registration on the National Register of Fingerprint Experts should be reviewed. If it continues in use it should be revised to ensure that the criteria for registration and the records are kept up to date and that …
No response yet
FP77 — Recommendation 77
Recommendation: A system should be devised whereby any authorisation of fingerprint examiners under section 280 would be confined to the authorisation of individuals who are employed by an institution which has achieved appropriate accreditation. It would be for the Scottish Government …
No response yet
FP76 — Recommendation 76
Recommendation: The system for authorisation under section 280 of the Criminal Procedure (Scotland) Act 1995, so far as relating to fingerprint examiners, requires review.
No response yet
13 — Accountability and regulation of managers
Recommendation: i. DHSC and NHS England must develop and put in place a barring system for all managers (clinical and non-clinical) by September 2027. It should be reviewed in 2030 with a view to moving to a full statutory regulation system …
Gov response: It recommends new regulation on NHS managers, not just on clinical professionals. The government has consulted on and confirmed plans to apply a barring scheme to senior leaders and managers, not just to clinicians, so …
Accepted in part
FR-8 — Registration in Young Offender Institutions
Recommendation: The Inquiry recommends (as originally stated in its Sexual Abuse of Children in Custodial Institutions: 2009-2017 Investigation Report, dated February 2019) that the UK government introduces arrangements for the professional registration of staff in roles responsible for the care of …
Gov response: We accept the need for registration, noting that internal registration is most appropriate for the young offender institution and secure training centre workforce. We are exploring proposals for how it could operate.
Accepted in part
FR-7 — Registration of Care Home Staff
Recommendation: The Inquiry recommends (as originally stated in its Interim Report, dated April 2018) that the UK government introduces arrangements for the registration of staff working in care roles in children's homes, including secure children's homes. Registration should be with an …
Gov response: We accept that rigorous registration of staff working in care roles in children’s homes is essential and we are looking at how best to implement this as part of the Stable Homes, Built on Love …
Accepted in part
63 — Extend TRA jurisdiction to teaching assistants
Recommendation: The Department for Education should amend the Teachers' Disciplinary (England) Regulations 2012 to bring all teaching assistants, learning support staff and cover supervisors within the misconduct jurisdiction of the Teaching Regulation Agency. The Department for Education and the Welsh Government …
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
31 — DBS and training compliance for Church officers
Recommendation: Individuals engaged in regulated activity who have failed to undergo a DBS check or complete compulsory training should not be permitted to hold voluntary offices within the Church. Failure by ordained clergy to comply with either requirement should result in …
No response yet
27 — Professional registration for custodial care staff
Recommendation: As the Inquiry set out in its Interim Report, professional registration of the workforce in settings responsible for the care of vulnerable children complements regulation of institutions by a separate, independent regulator. The Government has agreed in principle that professional …
No response yet
24 — Registration of children's home care staff
Recommendation: The Chair and Panel recommend that the Department for Education introduces arrangements for the registration of staff working in care roles in children's homes. Registration should be with an independent body charged with setting and maintaining standards of training, conduct …
Gov response: 56. The Government agrees in principle that further workforce regulation could provide an effective additional means of protecting children. We are mindful that introducing professional registration for all staff in care roles in children’s homes …
Accepted in part
R9 — GP certification of fitness for NHS employment
Recommendation: We recommend that consideration be given to how General Practitioners might, with the candidate's consent, be asked to certify that there is nothing in the medical history of a candidate for employment in the National Health Service which would make …
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
R7 — Criteria for management referrals to occupational health
Recommendation: We recommend that procedures for management referrals to Occupational Health should make clear the criteria which should trigger such referrals (para 5.5.14).
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
R6 — Sickness records available to occupational health
Recommendation: We recommend that the possibility be reviewed of making available to Occupational Health departments any records of absence through sickness from any institution which an applicant for a nursing post has attended or been employed by (para 5.5.14).
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
R5 — Health screening for newly qualified nurses
Recommendation: We recommend that nurses should undergo formal health screening when they obtain their first posts after qualifying (para 5.5.13).
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
R4 — No nursing employment where major personality disorder
Recommendation: We recommend that no candidate for nursing in whom there is evidence of major personality disorder should be employed in the profession (para 5.4.11)
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
R1 — Sickness-absence record for entrants to nursing
Recommendation: We recommend that for all those seeking entry to the nursing profession, in addition to routine references the most recent employer or place of study should be asked to provide at least a record of time taken off on grounds …
Gov response: Recommendation 1. We recommended that, for all those seeking entry to the nursing profession, in addition to routine references the most recent employer or place of study should be asked to provide at leas: a …
Accepted
F191 — Recruitment for values and commitment
Recommendation: Healthcare employers recruiting nursing staff, whether qualified or unqualified, should assess candidates' values, attitudes and behaviours towards the well-being of patients and their basic care needs, and care providers should be required to do so by commissioning and regulatory requirements.
Gov response: Accepted. The Government’s Mandate to Health Education England contained a requirement to ensure that selection into all new NHS-funded training posts incorporates testing of values-based recruitment. NHS England is working with Health Education England and …
Accepted
BAHA-73 — Retaining Detention Expertise
Recommendation: In reducing the number of firm base unit custody facilities, the MoD should be careful not to erode the unit level operational detention expertise which is provided to a Battlegroup by the attendance of unit provost staff on the AAUCSC, …
Gov response: I can inform this House that I am accepting in principle all of his recommendations with one reservation.
Accepted in part
COVID-M2.1 — NI CMO Independence
Recommendation: The Department of Health (Northern Ireland) should reconstitute the role of the Chief Medical Officer for Northern Ireland as an independent advisory role. The Chief Medical Officer for Northern Ireland should not have managerial responsibilities within the Department of Health …
Gov response: Accepted Following restructuring of the Department of Health in November 2023, the Population Health Directorate, the Health Protection Directorate, the Emergency Planning Resilience and Response Directorate and the Quality, Safety and Improvement Directorate were moved …
Unknown
172 — Three-year qualification course
Recommendation: A three-year qualification course for social workers should be introduced as soon as possible (19.8).
Unknown
169 — Self-governing social work profession
Recommendation: ADSW should consider the taking of appropriate initiatives to develop a centralised self-governing profession of social worker in Scotland (19.4).
Unknown
24 — GWT records of maintenance staff competencies
Recommendation: GWT should maintain full records of competencies for all maintenance staff as required by job descriptions and safety responsibility statements (paras 6.8, 15.6).
Unknown
21 — Controllers' posts designated safety-critical
Recommendation: Controllers’ posts in Railtrack and TOCs should be designated as “safety-critical” as defined in the Railways (Safety Critical Works) Regulations 1994 (para 9.15).
Unknown
36 — Training before taking management control
Recommendation: No clinician should take effective control of a management position until trained in all necessary management techniques and in any relevant legal requirements.
Unknown
26 — Formal joint annual appraisal
Recommendation: There shall be formal annual appraisal of an individual by both parties. They shall share their information in line with the duty of utmost good faith in order to draw up a joint statement of aims in the following 12 …
Unknown
121 — Limit interviews per interviewer per day
Recommendation: No more than two investigative interviews per interviewer per day should be undertaken and their workloads should be regularly monitored (17.61).
Unknown
25 — Amendment of Safeguarding Vulnerable Groups Act 2006
Recommendation: The Chair and Panel recommend that the Home Office ensures that the Safeguarding Vulnerable Groups Act 2006 is amended so that, where a fitness to practise hearing has been conducted by the keeper of a relevant register and has resulted …
Gov response: 60. The Home Office therefore considers that automatic barring would be disproportionate. Further, as the behaviour or incident prompting the fitness to practise hearing will have been referred to the DBS by the employer under …
Not accepted
R8 — Apply ANHSOP Chairman's suggestion in practice
Recommendation: We recommend that further consideration be given to how the suggestion of the Chairman of the Association of NHS Occupational Physicians (see para 5.5.16) could be applied in practice (para 5.5.17).
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
WATE-(24) — Mandate stringent, independent vetting for all foster parent applications, especially staff
Recommendation: Similar vigilance should be mandatory in relation to all applications for approval as foster parents. In particular, any application to foster by a member of a local authority's child care staff should be stringently vetted by a social worker who …
Unknown
WATE-(23) — Periodically audit Social Services staff recruitment and management vigilance
Recommendation: Social Services Departments should be reminded periodically that they must exercise vigilance in the recruitment and management of their staff in strict accordance with the detailed recommendations of the Warner committee917; and compliance with them by individual local authorities should …
Unknown
FENN-96 — Allocate physically suitable staff to roles, ensuring station safety balance
Recommendation: London Underground shall only allocate staff to a role for which they are physically suitable. In the cause of safety, a proper balance must be ensured at each station.
Unknown
BRIS-89 — Involve public, employers, and professional groups in revalidation processes
Recommendation: The public, as well as the employer and the relevant professional group, must be involved in the processes of revalidation.
Unknown
BRIS-88 — Mandate periodic revalidation for all healthcare professionals in employment contracts
Recommendation: Periodic revalidation, whereby healthcare professionals demonstrate that they remain fit to practise in their chosen profession, should be compulsory for all healthcare professionals. The requirement to participate in periodic revalidation should be included in the contract of employment.
Unknown
Prevention of Future Deaths reports(39)
Jack William Payton
Concerns: The coroner observed that the workload and working hours of two control room staff appeared to detrimentally affect their judgement and subsequent handling of the incident.
Response (Avon and Somerset Police): • Avon and Somerset Police stated it would commission an independent assessment of current shift patterns and their effects on staff. • The findings of this assessment would be reviewed … (AI summary)
Responded
Karl Doran
Concerns: Beamish Museum had not conducted appropriate risk assessments to ensure the safety of volunteers and lacked direct or indirect managerial supervision of their activities.
Overdue
Neil Carter
Concerns: The coroner noted repeated failures to perform basic nursing observations, inadequate staffing levels and skill mix on the ward, and a lack of staff discipline. There was also a deliberate falsification of nursing records.
Response (CQC): • The CQC conducted multiple inspections of The Priory Hospital Roehampton, identifying non-compliance in areas such as staffing and observation training, and requiring the provider to take action. • Subsequent … (AI summary)
Response (Priory Group): • The individual responsible for record falsification and missing observations was dismissed and referred to the Nursing and Midwifery Council. • The hospital implemented changes to staff induction, reviewed its … (AI summary)
Responded
Lalitaben Patel
Concerns: The coroner identified inadequate systems for assessing and signing off locum consultant surgeons as competent for independent practice, noting that while one hospital had improved, similar risks might exist elsewhere.
Response (Department of Health and Social Care): • The Department of Health and Social Care noted that the specific Trust had addressed concerns regarding recruiting and management practices. • The government welcomed recommendations from a 2013 working … (AI summary)
Responded
Lloyd Butler
Concerns: The coroner noted a lack of professionalism and leadership in the custody suite, where inappropriate behaviour and banter were common. There was insufficient evidence of guidance or training for staff on acceptable conduct, indicating a need for cultural change within custody suites.
Response (West Midlands Police): • West Midlands Police (WMP) established a central department for custody management and reduced the number of custody suites. • WMP launched an internal 'Pride in our Police' campaign and … (AI summary)
Responded
Thomas Warren
Concerns: The coroner noted that the NHS Trust did not require its recruitment agency to perform registration or fitness-to-practice checks on a locum doctor. The Trust was also unaware of prior concerns and ongoing investigations regarding the doctor's performance in other health services.
Response (Department of Health): • The Department of Health established a Secondary Care Locum Doctor Working Group in November 2013, which made recommendations to strengthen arrangements for locum doctor recruitment and quality assurance. • … (AI summary)
Response (Lewisham Greenwich NHS Trust): • The Trust confirmed that all staff recruitment, including agency medical staff, is completed in line with NHS Employment Check Standards. • The Trust stated it regularly reviews policy and … (AI summary)
Overdue
Pauline Edwards
Concerns: The coroner noted that UK hospitals may be unaware of the requirement to accept EU-trained doctors' qualifications, potentially leading to these doctors practicing unsupervised and increasing patient risk.
Response (Department of Health): • The Department stated it is working with the General Medical Council to strengthen processes for confirming equivalent curriculum content for EU medical specialties. • The Department stated it is … (AI summary)
Responded
Simon Tree
Concerns: Concerns are raised regarding the security of the airlock system, which has allowed patients to 'tailgate' visitors and leave the unit. The report also notes a lack of monitoring by staff in the reception area.
Response (Surrey Borders Partnership): • A Security Manager has been recruited to undertake annual site security audits at all inpatient sites. • An out-of-hours receptionist has been employed to support ward staff during visiting … (AI summary)
Responded
Thor Dalhaug
Concerns: The coroner raised concerns about the lack of supervision for an operating surgeon using an inappropriate delivery technique, along with deficiencies in contemporaneous record-keeping and candour. The Serious Untoward Incident investigation was also deemed inadequate, with no disciplinary action taken.
Response (United Lincolnshire Hospitals NHS Trust): • The Trust implemented new induction and supervision processes for junior doctors, including a week of supernumerary activity. • The Trust significantly reviewed and changed its Serious Incident investigation processes, … (AI summary)
Responded
Laurence Boyens
Concerns: Coroner noted insufficient compliance with drug dependence guidelines, specifically regarding blood pressure monitoring before Methadone/Buprenorphine administration and escalation of low readings. Gaps in record-keeping and recognition of patient drowsiness were also identified.
Response: • The organisation commenced a review of its decision to close a case regarding Dr Amayo's care. • The organisation obtained the doctor's comments as part of this review. • … (AI summary)
Response: • The Nursing and Midwifery Council (NMC) stated it would conduct an initial assessment of the referral. • The NMC indicated it would determine how to proceed following the assessment. … (AI summary)
Overdue
Mary Hyden
Concerns: The coroner noted concerns regarding a consultant neurologist working excessive hours, including 7 days a week, which presented an increased potential for errors.
Response (University Hospitals of North Midlands NHS Trust): • The consultant's job plan was reviewed in July 2015. • A new job plan, effective from 1 October 2015, will reduce clinical sessions to support work-life balance. • The … (AI summary)
Responded
Bradley Hooper
Concerns: A 16-year-old marshall was positioned contrary to club rules, used a mobile phone, and faced away from riders, delaying warning flag deployment. The coroner also noted a lack of guidance in the MCF Code of Practice regarding smartphone use by marshalls.
Response (Portsmouth Motocross Club): • The club stated that less experienced marshals are placed at low-risk marshal points, and all marshals are instructed on flag usage. • Marshals are informed not to use mobile … (AI summary)
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
Steven Rogers
Concerns: The coroner noted a patient was discharged as medically fit by a doctor who had not seen them, relying on nurse information and colleagues' assessments. Concerns were also raised about the erroneous omission of the patient's long-acting insulin during their hospital stay, which altered their medication regime.
Response (Steven Rogers): • The Trust has a risk assessment in place regarding paper charts and reminds staff to check for them. • A specialist "Task & Finish Group" is in place to … (AI summary)
Responded
John Rogers
Concerns: Systems within BCUHB are not sufficiently robust to ensure staff are appropriately qualified for their roles and that their training and qualifications remain up to date.
Response: • The Health Board stated that specific actions had been undertaken and completed to assure staff training and qualifications on the unit and for on-call arrangements. • The Health Board … (AI summary)
Responded
Jakub Moczyk
Concerns: Pre-fight medical checks were incomplete for boxers, including the deceased's opponent, and medics did not identify this or inform the referee. During the fight, medics did not assess the opponent's fitness after he vomited, relying on the non-medically qualified referee.
Response (Lifeshield Medical Services Ltd): • The organisation stated it is no longer covering boxing events. • The organisation stated it had informed the referee and promoter about which fighters had not received medical examinations. (AI summary)
Responded
Peter O’Donnell
Concerns: The coroner noted missing formal agreements for independent consultant reviews and undocumented communication/escalation procedures. Concerns were also raised about a single resident medical officer providing 24/7 post-operative care without clear hospital oversight, and the absence of protocols for transferring unwell patients.
Response (Department of Health): • The Care Quality Commission (CQC) conducts inspections of independent hospitals, including reviews of patient risk, escalation, and transfer processes, and uses incident and inquest information for future inspection planning. … (AI summary)
Responded
Cyril Anderton
Concerns: Medical staff did not attempt CPR after consulting the wrong set of medical notes.
Overdue
Kevin Miles
Concerns: The coroner noted that the process for certifying divers fit to dive does not require obtaining the diver's GP records, identifying a risk of health conditions being misreported or undisclosed. This absence could lead to divers being certified unfit to dive, endangering themselves and potential rescuers.
Response (UKDMC): • The UKDMC discussed the coroner's concerns regarding the diver medical certification process. • The UKDMC stated it saw no reason to alter the current system. • It described the … (AI summary)
Overdue
Polly Drew
Concerns: The recruitment process for a doctor with significant responsibility and access to anaesthetic drugs was inadequate, leading to concerns about the appointed doctor working alone and posing potential risks.
Overdue
Alex Blake
Concerns: The coroner raised concerns regarding the reliability of observations and recorded evidence by three staff members, noting inconsistencies in their accounts and suggesting that observations may not have been performed or that false evidence was provided.
Response (NMC): • The NMC passed the report concerning two registered nurses to its Fitness to Practise team for further investigation. • The Employer Link Service contacted the trust and NHS Professionals … (AI summary)
Response (NHS Professionals): • NHS Professionals obtained all information relating to the case from South London & Maudsley NHS Foundation Trust upon receipt of the report. • The Interim Clinical Governance Director and … (AI summary)
Responded
Russell Bowry
Concerns: Employers may delegate work at height safety to riggers without designing adequate fall protection systems or ensuring clipping points can hold a falling person. The industry structure limits riggers' influence over safety measures, leading to routinely encountered unsafe practices.
Overdue
Ifeoma Onwuka
Concerns: The coroner identified concerns regarding an on-call consultant's apparent lack of confidence to perform emergency hysterectomy without a second consultant, insufficient professional curiosity about the cause of DIC, and a lack of leadership in patient care. This may place pregnant women requiring emergency surgery at risk.
Overdue
Arthur Hughes
Concerns: The coroner noted a lack of protocol for observing and assessing locum staff in practice, potentially leading to them working beyond their capabilities. There was also a reluctance at a managerial level to supplement locum references with telephone calls.
Response (Betsi Cadwaladr University Health Board): • The Standard Operating Procedure for locum appointments was amended to ensure central collection and follow-up of local induction and assessment of practice pro forma, with revised implementation dates set … (AI summary)
Overdue
Macloud Nyeruke
Concerns: The Trust was unaware of the deceased's medical conditions, leading to work on wards with multi-resistant organisms, and there was scant evidence of appropriate PPE training for agency staff. Nursing agencies supplied support workers without knowledge of their health vulnerabilities, creating infection risks for staff and patients.
Response (Leeds Teaching Hospitals NHS Trust): • Reed agency has made the 'fit tested' status visible in the Health Roster system for agency staff, and additional fit testing is being provided. • The Trust plans to … (AI summary)
Response (Reed Specialist Recruitment Ltd): • Reed investigated the matter and performed audits on ID Medical to confirm vetting, medical fitness, and training for the individual. • Reed escalated the matter to the Employment Agency … (AI summary)
Response (Employment Agency Standards): • The Employment Agency Standards Inspectorate stated it would investigate the matter further. • The investigation would include assessing compliance with regulations concerning information obtained from hirers, confirmation about work-seekers, … (AI summary)
Responded
Rachel Johnston
Concerns: The coroner noted Pirton Grange lacked a robust policy for investigating staff misconduct, including imposing suspensions and reporting to the NMC. Following a death, initial investigation and reporting of nurse conduct to the NMC were inadequate and delayed.
Response (Holmleigh Care Homes Ltd): • The Home engaged a solicitor's firm to provide independent oversight and advice on HR matters, investigations, disciplinary actions, and professional body reporting. • The Home appointed a new Registered … (AI summary)
Overdue
Ian Taylor
Concerns: The coroner identified concerns regarding PC's fitness to serve, highlighting dismissive comments about an individual's distress and the officer's failure to acknowledge an inadequate risk assessment. No evidence of post-incident supervision or training was presented to address these attitudinal deficits.
Response (Royal College of Emergency Medicine): • The Royal College of Emergency Medicine stated that the provision of medical cover to police custodial units does not fall within its remit. • It noted that it does … (AI summary)
Response (Independent Office for Police Conduct): • The Independent Office for Police Conduct (IOPC) determined that the officer's behaviour did not meet the threshold for a conduct matter under the Police Reform Act 2002. • The … (AI summary)
Response (Metropolitan Police Service): • The Metropolitan Police Service confirmed that the officer's conduct did not meet the threshold for justifying disciplinary proceedings. • The officer will be referred to the Reflective Practice Review … (AI summary)
Response (Department of Health and Social Care): • The Department stated it would support the Home Office in the process of considering whether salbutamol inhalers should be available to police officers. • The Department indicated it would … (AI summary)
Responded
Kate Hyatt
Concerns: The coroner expressed concern that the Hands of Light Academy dispensed hallucinogenic substances to attendees, potentially including mentally unwell individuals, without adequate consideration of the impact, particularly on those with psychosis.
Response (Hands of Light Academy): • The Academy stated it does not dispense hallucinogenic substances to students. • The Academy confirmed it undertakes screening of all prospective students and committed to ensuring continued thorough screening, … (AI summary)
Responded
Ruwaida Adan
Concerns: The coroner identified ongoing safety risks at Capital Karts due to inadequate track marshal checks for loose hair and clothing. Concerns were raised about a lack of improved training and monitoring for marshals, and management's commitment to addressing these deficiencies.
Response (Capital Karts): • The company implemented a multi-stage safety check process, beginning at booking and continuing through reception, briefing, and pit lane, to ensure the removal of loose clothing and securing of … (AI summary)
Responded
Sean Duignan
Concerns: The coroner identified serious failures in the management and monitoring of the South Base Armoury access system, which repeatedly malfunctioned and permitted incorrect single access to an officer. The override key PIN being common knowledge also enabled potentially unfettered access.
Response (HMICFRS): • HMICFRS will ensure the College of Policing and the National Police Chiefs’ Council issue a national circular to all forces by 31 March 2023, including lessons learned and a … (AI summary)
Response (Bedfordshire Police): • Bedfordshire Police rectified incorrect armoury access levels, restricted single access to specific roles, and implemented monthly reviews of these restrictions. • A process was introduced to notify officers with … (AI summary)
Response (HMICFRS): • Bedfordshire Police reduced single access to the armoury to five specific roles and removed access from national firearms instructors. • The force implemented new systems and procedures for restricting … (AI summary)
Responded
Tarik Drakes
Concerns: Insufficient staffing and monitoring at Dorset Lodge permits unmonitored entry by non-residents and drug use within the premises. Additional concerns include agency staff not conducting key worker sessions and a non-functional out-of-hours emergency contact.
Response (BCHA): • BCHA has implemented additional Night Response Team presence at Dorset Lodge and plans to enhance evening presence across sites. • BCHA, in collaboration with partners, is reviewing multi-agency 'Link … (AI summary)
Responded
Barbara Rymell
Concerns: The coroner raises concerns about the insufficient English language proficiency of care workers, noting that the current B1 test level is inadequate for communicating effectively with emergency medical professionals when caring for vulnerable individuals.
Response (Home Office): • The Home Office stated it did not consider raising English language requirements for Skilled Workers to be appropriate or practical. • The Government announced that from Spring 2024, only … (AI summary)
Overdue
Michael Dalkin
Concerns: Inadequate licensing and deployment of door supervisors, including the use of unlicensed staff and inaccurate recording of operational numbers on SIA registers.
Response (Goldies Bar): • The premises licence was amended to require the use of an external security agency to provide registered door supervisors. • The amended licence stipulates minimum numbers of door supervisors … (AI summary)
Pending
Alice Clark
Concerns: The coroner identified concerns regarding unsafe paramedic driving standards and the insufficient handling of related complaints. Additionally, there was no formal complaint procedure in place, and questions were raised about the independence and regularity of driving assessments.
Response (South East Coast Ambulance Service): • A new driving policy, published in August 2023, includes mechanisms for staff to raise concerns about driving standards, supported by a dedicated Microsoft form and a Speak Up campaign … (AI summary)
Responded
Lee Stammers
Concerns: Poor documentation, communication, and systems meant urgent tests were not undertaken due to inaccurate medical records. The report also identified that tests could be cancelled by unidentified staff without rationale or accountability.
Response (Doncaster and Bassetlaw Teaching Hospitals): • The Emergency Department implemented identified Immediate Safety Actions concerning communication and documentation practices. • Restrictions were implemented for student nurse access to the Symphony system, and mandatory login requirements … (AI summary)
Responded
Jack Brown
Concerns: The coroner identified that care agencies supplying staff to care homes are unregulated, meaning their recruitment processes are not inspected. This creates a risk that unsuitable agency staff may be providing care to vulnerable people without basic checks as to experience and suitability.
Response (Department for Health and Social Care): • The department revised and expanded the Care Workforce Pathway, a national career structure for adult social care. • The department launched the Adult Social Care Learning and Development Support … (AI summary)
Responded
[REDACTED]
Concerns: Concerns persist regarding the quality and accuracy of patient observations, including potential falsification and inadequate 1:1 monitoring by staff. Other issues include ineffective auditing of clinical records and a lack of staff guidance if the door-locking system fails.
Response (East London NHS Foundation Trust): • The Trust is implementing a two-phase project to reduce intermittent observations and enhance relational, therapeutic engagement, with testing on ten inpatient wards from April to October 2025 and subsequent … (AI summary)
Responded
Syeda Fatima
Concerns: The coroner noted significant cultural tensions between midwifery and obstetric staff at Good Hope Hospital's maternity unit, which may have delayed urgent medical action. A wider hierarchical and bullying culture was identified, hindering staff contribution to decision-making and causing anxiety in urgent situations.
Response (University Hospitals Birmingham NHS Foundation Trust): • The Trust will implement twice-daily multidisciplinary 'Team of the Shift' huddles to strengthen communication and escalation. • The Trust will provide enhanced multi-professional leadership development and civility training, including … (AI summary)
Responded
Valerie Gibson
Concerns: The coroner noted staff uncertainty and confusion in medication dispensing and administration, leading to unclear records and a risk of incorrect dosing. Concerns also included inadequate checks of patient possessions and inconsistent use of electronic medication systems.
Response (Cumbria Northumberland Tyne and Wear NHS Foundation Trust): • The Trust has updated Omnicell training, guides, and nursing staff medicines competencies, alongside its Medicines Optimisation Policy and e-learning packages. • It has adopted the '6 Rights of Medicines … (AI summary)
Responded
Select committee recommendations(74)— showing 50 strongest matches
#18 —
Recommendation: In increasing the resilience of institutions and technology, the UK must not lose sight of people-based threats. People are an organisation’s greatest asset, but they can also be its most unpredictable vulnerability. The UK’s adversaries can be expected to target …
#24 —
Recommendation: We recommend that the Charter remove both political and geographical appointments to the BBC Board. The government should also consider whether the appointment of the Chair of the BBC could be made by an independent body, provided it was subject …
#23 —
Recommendation: The experience of recent high-profile crises has demonstrated the need for robust and effective leadership and governance structures at the BBC. We want the BBC Board members to be chosen according to the skills, experience, and vision needed to lead …
#15 —
Recommendation: There is scope for the Civil Service Commission to play a role in the dismissal of senior civil servants on performance or conduct grounds, by ensuring due process is followed.
Response attribution not verified
#14 —
Recommendation: In the rare circumstances in which a permanent secretary must be dismissed on performance or misconduct grounds this should be treated wholly as a human resources matter, following due process. We welcome the current process of performance and misconduct management …
Response attribution not verified
#5 —
Recommendation: In our view “merit” includes having the right personality and characteristics to carry out the tasks required at a particular time. We are not convinced the Recruitment Principles need to be amended to reflect this. But it should be implicit …
Response attribution not verified
#16 —
Recommendation: Though there is substantial variation, in many cases, those procuring and recommending homecare services appear ill-equipped to do so. In some cases, expertise is missing; in others, there is insufficient information. Given this, and the clear commercial incentives for manufacturers …
Response attribution not verified
#131 —
Recommendation: Whilst commercial property acquisition can present exciting opportunities for local authorities, there are risks if insufficient expertise is accessed or held within the authority. The Government should ensure that local authorities seeking to acquire new commercial properties in their local …
Response attribution not verified
#39 —
Recommendation: The Government should ensure that a new independent single register of interpreters is established which ensures a high standard of vetting and entry criteria, so that highly skilled interpreters have access to work across the criminal justice system. (Paragraph 175) …
Response attribution not verified
#38 —
Recommendation: A number of registers exist which allow interpreters to access work in the courts depending on whether it is an MOJ booking or off-contract booking. In order for interpreters to access work across the criminal justice system, they will require …
Response attribution not verified
#26 —
Recommendation: We are concerned that many local authorities do not have enough suitability skilled staff to robustly regulate and enforce standards in their private rented markets. If not addressed this problem threatens to undermine the steps the government is taking to …
Response status not verified
#25 —
Recommendation: National standards should set proportionate and fair requirements for key elements of driver competence, including spoken English language proficiency and appropriate knowledge of the areas in which drivers operate. (Recommendation, Paragraph 94)
Response status not verified
#24 —
Recommendation: The current inconsistent expectations for English language proficiency and local knowledge across different licensing authorities can have negative effects on the safety and confidence of passengers and drivers alike. (Conclusion, Paragraph 93)
Response status not verified
#14 —
Recommendation: The government should ensure that guidance clearly links the criteria for making a fit and proper person judgement to national licensing standards. (Recommendation, Paragraph 65)
Response status not verified
#13 —
Recommendation: Defining “fit and proper” in statute would not be straightforward, and any definition would need to preserve a degree of flexibility for licensing authorities to exercise judgement in individual cases. The consequences of getting decisions wrong are serious, however, and …
Response status not verified
#12 —
Recommendation: We agree with the minister that every local authority must require drivers to have an enhanced DBS check and to be checked against the adults’ and children’s barring lists. We also recommend that requirements for safeguarding training and clear requirements …
Response status not verified
#11 —
Recommendation: An enhanced DBS check is the highest level of criminal record check available, yet it seemingly does not guarantee that licensing authorities receive all the information they need to make sound judgements about licence applications. We are concerned that the …
Response status not verified
#16 —
Recommendation: It is also important that the alignment in aid and diplomacy is not used as an excuse to roll back the reforms that have ensured the UK’s IMF and World Bank positions are still staffed by individuals with experience of …
Response attribution not verified
#2 —
Recommendation: We are satisfied that Mr Dominic Harris has the personal independence and professional competence to be the Pensions Ombudsman and the Pension Protection Fund Ombudsman. We wish him every success in his new role, and we look forward to working …
Response status not verified
#1 —
Recommendation: We would like to put on record our thanks to Antony Arter for his service as Pensions Ombudsman and the Pension Protection Fund Ombudsman over the past seven years.
Response status not verified
#40 — Systemic working condition issues persist in film and HETV, causing worker loss.
Recommendation: The film and HETV industry will continue to lose workers if it does not address systemic issues with working conditions, and the Government should hold it accountable for doing so. The prioritisation of the predominantly freelance creative industries in the …
Response attribution not verified
#15 — Require the next permanent or interim CCRC Chair to be solely dedicated to the organisation.
Recommendation: The next permanent chair or interim chair of the CCRC should be dedicated to the organisation above all other duties. (Recommendation, Paragraph 50)
Response attribution not verified
#14 — Former CCRC Chair's multiple roles contributed to perceived lack of focus and CCRC failings.
Recommendation: The former Chair held multiple executive roles which gave the perception of a lack of focus and may have contributed to the CCRC’s failings. (Conclusion, Paragraph 49)
Response attribution not verified
#13 — Mandate the CCRC Chair demonstrate criminal justice expertise and commitment to upholding CCRC independence.
Recommendation: The Chair should have a background in criminal justice, have recognised experience in that field and, above all, be absolutely dedicated to the CCRC’s purpose of identifying miscarriages of justice and upholding its independence. (Recommendation, Paragraph 48)
Response attribution not verified
#186 — Align HMPPS personnel vetting requirements with tier-one security agencies and mandate lifelong vetting
Recommendation: HMPPS must immediately commit to aligning its personnel vetting requirements with those of other tier-one security and law enforcement agencies, such as the police. While the nature of the work differs, the threat profile is comparable. This alignment must establish …
Response attribution not verified
#7 — Amend prison staff recruitment to grant Governors ultimate decision and mandate face-to-face interviews.
Recommendation: Governors must have the ultimate decision on the recruitment of staff who work in their prison. HMPPS must amend its recruitment process to ensure that all frontline staff, including prison officers, undergo a mandatory face-to-face interview process led by Governors …
Response attribution not verified
#16 — Numerical recruitment targets for neighbourhood policing risk cheap hires and lack of experienced officers.
Recommendation: We commend the efforts of police forces to maintain business-as- usual policing, particularly the importance attached to maintaining neighbourhood policing. Nonetheless, the disorder and subsequent investigations have had a knock-on impact on other areas of policing, including neighbourhood policing. The …
Response attribution not verified
#21 —
Recommendation: Formal departure processes should be set out in writing, requiring ministers and the Prime Minister to explain to the Civil Service Commission—in private if necessary—their decision to remove and replace a senior civil servant . A written record of the …
Response attribution not verified
#20 —
Recommendation: While removal of senior civil servants on political or ideological grounds may be rare, we are concerned that recent examples may be an indication that there are insufficient safeguards around the departure of senior civil servants.
Response attribution not verified
#19 —
Recommendation: The Cabinet Secretary and Head of the Civil Service has a vital role in ensuring that individuals are not removed from their posts by a Prime Minister without due process. If the working relationship between a secretary of state and …
Response attribution not verified
#18 —
Recommendation: We recognise that for a permanent secretary fostering a positive relationship with the secretary of state is, in itself, a matter of performance. The Recruitment Principles require panels to assess a candidate’s ability to work with the minister as part …
Response attribution not verified
#13 —
Recommendation: We look forward to seeing the forthcoming work, promised by the Cabinet Secretary, on the rules concerning business appointments and the role of ACOBA in setting expectations for those seeking to enter the civil service. Regularisation of inward and outward …
Response attribution not verified
#8 —
Recommendation: Public statements by special advisers about the recruitment, performance or departure of civil servants are unacceptable as they risk giving the impression—or tolerating the reality—that special advisers are managing civil servants. Ministers are responsible for the actions of their special …
Response attribution not verified
#128 —
Recommendation: Successfully managing or regenerating commercial properties requires a specific set of skills. Representatives from Spelthorne Borough Council emphasised the need for internal experts with commercial expertise and mindset. 264 We heard concerns about the skills and capacity within local authorities, …
Response attribution not verified
#130 —
Recommendation: The FCA and PRA must do more to improve supervisory staff’s practical understanding of financial services firms. We recommend that the FCA and PRA explore developing a formal secondment system to both send supervisory staff out to regulated financial services …
Response attribution not verified
#128 —
Recommendation: We are concerned by evidence which indicated that there are inconsistencies in the quality of supervision. Firms should expect consistency in the staff that supervise them and supervisors who understand their business.
Response attribution not verified
#121 —
Recommendation: Other witnesses complained about the inconsistent quality of supervision and the rigidity in the application of rules, linking the lack of flexibility and agility in the supervisory processes to the prevalence of junior staff in supervisory roles. Lord Blackwell noted: …
Response attribution not verified
#119 —
Recommendation: ClearBank noted that the experience of supervisory staff has created difficulties for the regulators understanding and adapting supervisory processes to account for novel business models: “specifically for Embedded Banking, 190 regulators have struggled to understand how to best [oversee] the …
Response attribution not verified
#118 —
Recommendation: Some witnesses suggested that the experience and capacity of supervisors leads to slow and inefficient approval processes, which may impact on their ability to scale and grow. Witnesses noted that the limited resources allocated to smaller firms have introduced delays …
Response attribution not verified
#117 —
Recommendation: Whilst it is of vital importance that the firms which pose the greatest systemic risk to the UK financial system are appropriately supervised by knowledgeable and experienced staff, we were told that this concentration of experience has negative implications for …
Response attribution not verified
#15 —
Recommendation: There are indications that some museums and galleries may not have the financial management capability to manage future risks. For example, many have experienced significant churn in their senior financial leadership in recent years, while some have struggled to produce …
Response status not verified
#187 — Amend HMPPS recruitment to mandate face-to-face interviews by local governors for frontline staff
Recommendation: HMPPS must amend its recruitment process to ensure that all frontline staff, including prison officers, undergo a mandatory face-to-face interview process led by local governors. This critical step addresses the identified deficiency in governors not having direct involvement in the …
Response attribution not verified
#4 —
Recommendation: The Department relies heavily on museums and galleries and their boards to ensure their own financial resilience, but their boards are not consistently well-equipped to do this effectively. As arms-length bodies, museums and galleries have primary responsibility for their ongoing …
Response attribution not verified
#20 —
Recommendation: The government should not pursue its current preferred option of mandatory qualifications being implemented by designated professional bodies, such as The Property Institute, as leaseholders are clear that they do not have confidence in industry bodies to carry out this …
Response status not verified
#42 — Ensure all children's homes are led by registered managers; launch recruitment campaign.
Recommendation: The Department for Education must ensure that all children’s homes are led by a registered manager and set out the steps it intends to take to achieve this. Additionally, it should launch a recruitment campaign to raise the profile of …
Response attribution not verified
#17 —
Recommendation: The pandemic and increasing demand on the justice system will continue to put pressure on staff who are at the heart of ensuring prisons are well run, court backlogs are addressed, and probation services are effective. HMPPS told us of …
Response attribution not verified
#16 —
Recommendation: We received evidence from the Bar Council raising concerns around the safety of court staff during the pandemic. A recent survey they conducted showed 84% of barristers who attended court in December 2020 had concerns about their safety and wellbeing.23 …
Response attribution not verified
#2 —
Recommendation: We recognise that all prisons and other custodial institutions face additional pressures during the current covid-19 pandemic, but we do not consider those to be justification or excuse for the continued poor conditions at Rainsbrook and the repeated absence of …
Response status not verified
#24 —
Recommendation: Guidance to all Research Council staff should include a specific requirement to ensure representative Committees—for example, greater diversity could be achieved by appointing on potential, rather than on past achievements.
Response attribution not verified
#20 —
Recommendation: Some STEM researchers face a discriminatory working environment. Whilst this reflects inequities that exist elsewhere in society it is nevertheless a source of deep concern. The process of reducing and ultimately ending such prejudice will not be swift but is …
Response attribution not verified
HSSIB safety recommendations(8)
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
National bodies can support patient safety by developing credentialing systems which enable staff to verify their competencies when moving between NHS organisations.
Safety Observation
Oxygen issues during the COVID-19 pandemic
HSIB recommends that NHS England and NHS Improvement implement a process to provide ongoing assurance on the qualifications and experience of individuals identified in the health technical memorandum (HTM) for medical gas pipeline systems (MGPS), including how MGPS Authorising Engineers, …
Safety Recommendation
Wrong patient details on blood sample
Trusts should be aware of the increased risk of WBIT incidents occurring where there may be staff shortages and staff fatigue.
Learning Prompt
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS England and NHS Improvement supports clinical experts to work with professional bodies to develop training competencies for healthcare professionals with responsibility for caring for children with suspected or confirmed asthma.
Safety Recommendation
Suitability of equipment and technology used for continuous fetal heart rate monitoring
HSIB recommends that NHS England and NHS Improvement amends the ‘Saving Babies’ Lives care bundle version 2’ to enhance the role of the ‘fetal monitoring lead’ to include, training and competency checks of all maternity staff on the use and …
Safety Recommendation
Treating Covid-19 patients using continuous positive airway pressure (CPAP) outside of a critical care unit
As part of our final investigation report we have provided six safety questions to improve patient care and outcomes. Do you have an operational policy that includes the areas of the hospital where non-invasive respiratory support can be provided? Does …
Learning Prompt
Recognition of the acutely ill infant
It may be beneficial if there is system-wide assessment of the capacity of the medical and non-medical workforce to support safe and sustainable staffing in emergency departments caring for children in England. The intention of the following safety observation is …
Safety Observation
Wrong patient details on blood sample
Trusts can aim to understand the range of distractions staff face in different working environments and the compromises staff may have to make to deliver patient care.
Learning Prompt
NCEPOD recommendations(7)
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
CQC inspection actions(215)— showing 50 strongest matches
William Harvey Hospital
The trust should ensure staff receive appropriate ongoing or periodic supervision in their role to make sure competence is maintained. 18(2)(a): Staffing
Should Do
William Harvey Hospital
The trust must ensure all temporary staff are provided with an induction and are competent to work within a paediatric setting.
Must Do
West Cumberland Hospital
The trust must ensure that enough suitably, qualified, competence nursing staff are deployed.Regulation18(1)(2)(a).
Must Do
West Cumberland Hospital
The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.Regulation12(1)(2)(c).
Must Do
University Hospital of Hartlepool
The service must deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure that they can meet people’s care and treatment needs.
Must Do
The York Hospital
The trust should ensure that it follows the recommended period for repeating and recording Disclosure and Barring Service checks for directors.
Should Do
The York Hospital
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Must Do
The York Hospital
The trust must demonstrate its supports its staff by challenging unacceptable behaviours and language. This includes, but is not limited to, racism and discrimination.
Must Do
Sunderland Royal Hospital
The trust must ensure all staff have an appropriate disclosure and barring service check and ensure this is repeated where required or the risks of not repeating checks are considered and assessed.
Must Do
South Tyneside District Hospital
The trust must ensure all staff have an appropriate disclosure and barring service check and ensure this is repeated where required or the risks of not repeating checks are considered and assessed.
Must Do
Scarborough Hospital
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Must Do
Salford Royal Hospital
The service must ensure that they have enough medical or nursing staff to keep patients safe and that patients requiring one to one observations receive this level of care.
Must Do
Salford Royal Hospital
The service must ensure that there are sufficient numbers of both medical and nursing staff that can meet people's care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The trust must ensure that there are sufficient numbers and skill mix of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The service must ensure that there are sufficient numbers and skill mix of nursing staff that can meet peoples care and treatment needs and keep them safe from avoidable harm.
Must Do
Salford Royal Hospital
The trust must ensure that services are always safely staffed by people with the necessary skills, knowledge and experience.
Must Do
Royal Victoria Infirmary
The service must ensure that persons providing care or treatment to children and young people have the competence, skills, and experience to do so safely.
Must Do
Royal Victoria Infirmary
The service must ensure that there are sufficient numbers of suitably competent, skilled, medical staff to meet minimum staffing levels and meet the care and treatment needs of service users.
Must Do
Royal Victoria Infirmary
The service must ensure that persons providing care or treatment to children and young people have the qualifications, competence, skills, and experience to do so safely.
Must Do
Queen Elizabeth The Queen Mother Hospital
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust should ensure staff working under their enhanced observation framework are given suitable rest periods in line with their policy.
Should Do
North Middlesex University Hospital
The trust must ensure that HR processes particularly in relation to performance are completed in a timely manner.
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatpersonsprovidingcareortreatmenttoserviceusershavethequalifications,competence,skills,andexperiencetodososafely.Regulation12(1)(2)(c)
Must Do
Leicester Royal Infirmary
The trust must ensure there are always enough suitably qualified and skilled staff on duty.
Must Do
Kidderminster Hospital and Treatment Centre
Ensure an evidenced-based review of the nursing establishment (including skill-mix) is carried out to ensure there are sufficient staff with the right skills and experience to meet the needs of patients who attend the minor injuries unit.
Must Do
Kidderminster Hospital and Treatment Centre
The trust must ensure that consultant cover in the department meets national guidelines and there are always adequate numbers of suitably qualified nurses.
Must Do
Fleetwood Hospital
The trust must ensure the service has enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Must Do
Fleetwood Hospital
The trust must ensure they deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Must Do
Fleetwood Hospital
The trust must ensure the trust deploys sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Must Do
Fleetwood Hospital
The trust must ensure consultant staffing in the adult emergency department meet the minimum requirements of the Royal College of Emergency Medicine.
Must Do
Ellesmere Port Hospital
The trust must implement an effective system to ensure that medical, nursing and midwifery staff have the skills, knowledge, experience, and appraisal to care for and meet the needs of patients within their service area.
Must Do
Doncaster Royal Infirmary
The trust should consider a review of the timescales for Disclosure and Barring (DBS) re-checks for executive and non-executive directors to be undertaken sooner than every 10 years.
Should Do
Diana Princess of Wales Hospital
The service must ensure that persons providing care or treatment to service users have the qualifications, competence, skills, and experience to do so safely.
Must Do
Cumberland Infirmary
The trust should ensure that the number of staff requiring a signed off job plan meets the trust’s target. Regulation 18(2)(a).
Should Do
Cumberland Infirmary
The trust must ensure that enough suitably, qualified, competence nursing staff are deployed. Regulation 18(1)(2)(a).
Must Do
Cumberland Infirmary
The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely. Regulation 12(1)(2)(c).
Must Do
Cumberland Infirmary
The trust must ensure that enough suitably, qualified, competence nursing staff are deployed. Regulation 18(1)(2)(a).
Must Do
Cumberland Infirmary
The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills, and experience to do so safely. Regulation 12(1)(2)(c).
Must Do
Clatterbridge Hospital
The services should continue to monitor staff adherence to the trust’s values and behaviours.
Should Do
Castle Hill Hospital
The service must ensure that there are sufficient staff with the right qualifications, skills and training to keep people safe from harm.
Must Do
Broomfield Hospital
The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff.
Must Do
Blackpool Victoria Hospital
The service must ensure that there are sufficient numbers of suitably qualified, competent, skilled and experiences persons, to include resuscitation and safeguarding training.
Must Do
Airedale General Hospital
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced persons deployed to meet the needs of people who use the service.(Regulation18(1)).
Must Do
Victoria Infirmary
The service must ensure they hold a record of staff competencies that are up to date for all staff.
Must Do
Victoria Infirmary
The trust must ensure they deploysufficient number of suitably qualified, competent, skilled and experienced staff to ensure safe care and treatment is provided.
Must Do
Tower Hamlets Out of Hours GP Service
Review DBS security checking protocols so that the provider may be assured that they are up to date.
Should Do
The Sidings Medical Practice
Implement a system to monitor the prescribing competence of non-medical prescribers and regular review of their prescribing practice.
Should Do
Royal Derby Hospital
Ensure staff working hours are monitored and staff have the appropriate amount of compensatory rest.
Must Do
Royal Derby Hospital
Ensure the midwifery on-call rota is staffed by midwives who are suitably qualified, competent, skilled and experienced.
Must Do
Royal Bournemouth Hospital
The trust should continue to prioritise improving on their published Workforce Race Equality Standard results ensuring that black and minority ethnic staff do not experience higher levels of bullying, harassment or discrimination.
Should Do
HMICFRS recommendations(39)
FRS 2018-19 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: Devon and Somerset FRS cannot assure itself that operational members of staff meet the minimum fitness requirements to perform their role. Recommendation: By 28 February 2020, the service should provide an action plan that details how they …
Recommendation
FRS 2023-25 CoC Recommendations: Bedfordshire Fire and Rescue Service
Cause of concern: Bedfordshire Fire and Rescue Service can’t assure itself that its operational members of staff meet the minimum fitness requirements to perform their roles. Recommendation: Within 28 days, the service should provide an action plan that details 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 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 that arrangements for staff working on dual contracts meet statutory …
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 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: 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: 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 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 2023-25 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: The service lacks adequate organisational level plans that set out and bring together current and future workforce and skills requirements. The service doesn’t have in place adequate service-level processes to direct its recruitment and succession planning work. …
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
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 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 doesn’t have enough trained and experienced protection staff to implement its risk-based inspection programme and take proportionate action to reduce risk and enforce fire safety regulations. Recommendation: Within 28 days, the service should provide an …
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 support managers …
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 engage with …
Recommendation
FRS 2021-22 CoC Recommendations: Devon and Somerset Fire and Rescue Service
Cause of concern: The service has shown a clear intent from the executive board to improve the culture of the service. However, more needs to be done throughout the organisation. We have found evidence of poor behaviours that are not …
Recommendation
FRS 2023-25 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to make sure staff have access to gender-appropriate facilities. Access to welfare and hygiene facilities at incidents has been limited, and staff don’t have access to gender-appropriate uniform …
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 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service has shown an intent to improve its culture, with some staff reporting improvements across the service. However, more needs to be done. We found evidence of behaviours that weren’t in line with service values. We …
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
ICIBI immigration recommendations(1)
PPO death in custody recommendations(4)
The Governor and the Head of Healthcare
nurses always undertake their own assessment of a prisoners’ condition and do not accept an officer’s evaluation that the prisoner is apparently well.
The Governor and Head of Healthcare
review the two incidences in November 2021 where the HCA thought that prison staff gave her authority to move Mr Roalfe out of bed;
The Director of HMP Northumberland
The Director should review the process for allocating prisoners to positions of trust, to ensure there is an auditable record that relevant security information and potential risks have been fully considered.
The Governor
The Governor should commission a disciplinary investigation into Officer C’s and Officer A’s actions on the evening of 22 March 2023.
IOPC learning recommendations(4)
Collision following pursuit - Thames Valley Police, May 2019
The IOPC recommends that Thames Valley Police (TVP) makes sure that all relevant checks are carried out before officers who have transferred from another force are authorised to drive with Thames Valley Police. This should include ensuring that officers meet …
Recommendation - Warwickshire Police, May 2026
The IOPC recommends that should Warwickshire Police officers receive Reflective Practice Review Process (RPRP) for any minor misuse of Warwickshire Police computer systems, they conduct a review of that officer’s use of police computer systems on a regular basis. This …
Collision following pursuit - Thames Valley Police, May 2019
The IOPC recommends that all information regarding an officer’s driving authorisation/category is stored centrally within the TVP driving school and where there is a change the driving school ensures this change is reflected on its records without delay. A driving …
National recommendation - College of Policing, December 2019
When a police officer transfers from one force to another, their disciplinary history with their parent force is shared with the receiving force's vetting department. However, during an IOPC investigation it became apparent that not all vetting departments share the …
IMB individual recommendations(70)— showing 50 strongest matches
Birmingham (2023)
High rates of attrition are partly attributable to the appointments process which has resulted in too many unsuitable appointments. The process excludes the local Governor from involvement in the interview. Will HMPPS review the appointments process with a view to including local Governors in the selection process and a more rigorous assessment of a candidate’s suitability for the role of …
HMPPS
Rejected
Guys Marsh (2024)
The rise in assaults on prison staff and the worrying increase in the poor treatment of prisoners by some prison officers suggests a failure in the process of assessment, selection and training of officers. When will the Prison Service take action to address these shortcomings?
HMPPS
In Progress
Garth (2021)
The recruitment of uniformed staff needs urgent attention: • Each prison and each category of prison has its own needs in terms of staff recruitment and balance. • Each prison should have a say in the recruitment of individual officers in order to address the above requirements. This would be facilitated by face-to-face interviews in the prison. • Each prison …
HMPPS
Rejected
The Mount (2022)
On staffing levels and new recruits, the Prison Service needs to better appraise applicants as to their suitability for the role. A lot of effort and money is wasted when trainees leave because they cannot cope with the environment. Numbers recruited should not be the only measure. The number that finish their training who are still employed 12 months later …
HMPPS
In Progress
Garth (2022)
it is strongly suggested that only experienced officers should be seconded to prisons.
HMPPS
Rejected
Onley (2023)
What local actions are underway to improve officer staffing levels, given that prison officer shortages impacted on the daily life of prisoners and on the implementation of key work as intended in the offender management in custody (OMiC) model?
Governor / Director
Onley (2023)
What further support can be provided to ensure key work is delivered consistently and to a high standard for all prisoners despite the shortage of prison officers?
HMPPS
Garth (2023)
As above, to the Minister: staff recruitment and interview procedures need to be substantially changed to improve the process.
HMPPS
In Progress
Swinfen Hall (2024)
Why can staff who are completing their residential course prior to appointment to their prison not have their offer of employment withdrawn if, during the course or on completion, it is clear they do not have the capacity or suitability to take on the role of prison officer?
HMPPS
Rejected
Swinfen Hall (2024)
The HMPPS prison officer appointment process has resulted in some unsuitable appointments. Why are the Governing Governors not permitted to review the suitability of newly appointed band 3 staff prior to their starting the job at the prison?
HMPPS
In Progress
Garth (2024)
it is strongly recommended that applicants who are interest in joining the staff at Garth should visit the prison before interview and should be interviewed face-to-face by a panel that includes senior staff of the prison. It is essential that applicants fully understand what they are coming into and that management are as sure as possible that they have the …
Ministry of Justice
Partially Accepted
Garth (2024)
The whole process of recruitment and retention needs to be addressed with the Governor and senior management being included in the process and able to determine suitability of individual applicants for this prison.
HMPPS
In Progress
Garth (2024)
The whole policy and process of staff recruitment needs to be reviewed and revised as a matter of urgency, because many of the operational problems within the prison derive from the inadequacies of the current process.
Ministry of Justice
In Progress
Featherstone (2024)
The culture amongst staff remains problematic in some cases. We believe this issue is understood by the Governor, but continued vigilance is necessary to ensure these issues continue to be addressed.
Governor / Director
Wandsworth (2025)
Officer recruitment has been poor, leading to a high turnover of often unsuitable staff. Recruitment is handled centrally. Will the Prison Service consider allowing the prison to become involved in the process so that applicants receive a realistic impression of the role?
HMPPS
Implemented
Littlehey (2025)
The Board is, again, disappointed that, despite repeated requests for change, the IMB recruitment process continues to be inadequate and inappropriate to support the timely recruitment of candidates with the necessary qualities and skills. Again, the Board is eager to know what improvements the Minister plans to address this issue.
Ministry of Justice
In Progress
Featherstone (2021)
Shortly after appointment, the Governor recognised that there were some problems with the culture of some staff and took steps to improve it. More than a year on, our applications indicate that some of these problems may remain and vigilance will need to be maintained to ensure issues are addressed.
Governor / Director
Wandsworth (2023)
Staff recruitment is managed centrally. Would the Service consider involving HMP Wandsworth in the process to ensure that suitable staff are selected and given a realistic understanding of the role, thus reducing staff turnover?
HMPPS
Portland (2023)
Key work is crucial to the early identification of deteriorating mental health. If an individual has mental health issues it can adversely affect their ability to engage with learning and training. It therefore makes sense to prioritise key work over training and learning opportunities rather than being seen as an “add-on” with the option to drop it if staffing is …
Governor / Director
Peterborough (women) (2023)
Can the Director continue to focus on embedding quality key work?
Governor / Director
Peterborough (men) (2023)
Can the Director continue to focus on embedding quality key work?
Governor / Director
Pentonville (2023)
Will you commit to renewing the focus on key work to ensure that all prisoners can benefit from the valuable personal contact that this brings?
Governor / Director
Altcourse (2023)
Recruitment and retention of staff have been major concerns this year, particularly in the context of the transfer to Sodexo. These issues could undermine the stability and safety of the prison. Can the Board be reassured therefore that the recruitment and retention of staff remain the highest priority?
Governor / Director
Wandsworth (2024)
Staff recruitment is managed centrally. Would the Service consider involving HMP Wandsworth in the process to ensure that suitable staff are selected and given a realistic understanding of the role, thus reducing staff turnover?
HMPPS
Partially Accepted
Wandsworth (2024)
Officer recruitment has been poor, leading to a high turnover of often unsuitable staff. Recruitment is handled centrally. Will the Service consider allowing the prison to become involved in the process so that applicants receive a realistic impression of the role?
HMPPS
Partially Accepted
Swinfen Hall (2025)
The HMPPS prison officer appointment process continues to result in some unsuitable appointments. As governing governors are not permitted to review the suitability of newly appointed band 3 staff prior to their starting the job at the prison, is the Prison Service accepting that staff appointed lack confidence and competence?
HMPPS
In Progress
Bedford (2025)
What actions is the prison taking to address this [assaults on staff remain far too high]?
Governor / Director
Implemented
Manchester (2020)
What processes are being put into place to reduce staff sickness further, to provide a healthy workforce, with high levels of staff attendance?
Governor / Director
Long Lartin (2020)
The Board notes the unacceptably high number of assaults on officers in the segregation unit and the shortage of dedicated staff in this unit.
Governor / Director
In Progress
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport T3] The Home Office should arrange for the layout of the Terminal 3 office/reception area to be modified to enable both DCOs to exercise continuous surveillance of the detainees in their care (para. 7.2).
Home Office
Swaleside (2021)
The Board asks the Governor to note the high level of applications we have received complaining about staff. These should have translated into complaints sent to him and the DDC, and are at a much higher level than last year. (see section 8)
Governor / Director
Garth (2021)
Staff retention problems throughout HMPPS have increased throughout this period in large part because of the erosion of staff salaries and conditions of service. This matter needs to be urgently addressed and rectified.
HMPPS
In Progress
Foston Hall (2021)
The IMB is concerned about: increase in violent incidents due to an increase in assaults on staff
Governor / Director
Eastwood Park (2021)
What action is being taken to improve officer recruitment and retention at Eastwood Park?
Governor / Director
In Progress
Eastwood Park (2021)
Given the fluctuations in staffing levels caused by this pandemic, which are likely to continue for some time, will HMPPS ensure that prisons are staffed sufficiently to cope with this ongoing situation?
HMPPS
In Progress
Cookham Wood (2021)
Is the YCS confident that an appointment of a substantive postholder to the role of Governor at Cookham Wood can be made? And will there be adequate plans in place to support a smooth leadership transition when this eventually takes place?
HMPPS
In Progress
Wayland (2022)
The Board recommends to the Prison Service that the review of staff profiling for which we have called in previous reports, and for which we are now calling again, must take into account the context we have just described, at least until the balance of experience is restored.
HMPPS
Styal (2022)
There is an urgent need to review pay and conditions at all levels in the prison service to ensure the recruitment and retention of high quality staff.
HMPPS
Stocken (2022)
The Board has concerns about the performance of PeoplePlus, which is clearly not functioning well with low staff morale and some targets not being met.
Governor / Director
Send (2022)
Recruitment issues continue to impact on all areas of prison life including operational staff, healthcare and catering (3.1, 5.1, 6.1, 6.2).
HMPPS
In Progress
Pentonville (2022)
Will you introduce more initiatives (like Graduates Unlocked) to help raise the calibre of people applying to be prison officers?
HMPPS
Long Lartin (2022)
Will the Prison Service continue to provide a sufficient number of detached uniformed staff to ensure safety and fair and humane treatment for prisoners?
HMPPS
Bullingdon (2022)
There continues to be a high proportion of staff with limited experience. In some instances, these staff have no experience of the prison regime before Covid. How will the Governor ensure that these staff receive further appropriate training so that they can carry out their duties effectively?
Governor / Director
Garth (2023)
How and when does the Minister propose to tackle the urgent issue of uniformed staff recruitment and retention? Specifically, it is strongly recommended that applicants who are interested in joining the staff at Garth should visit the prison before interview and should be interviewed by a panel that includes senior staff at the prison. This should help ensure that new …
HMPPS
In Progress
Five Wells (2025)
How are all parties ensuring the safety of pharmacists and men at the dispensary hatches?
Governor / Director
Five Wells (2025)
How are all parties ensuring the safety of pharmacists and men at the dispensary hatches?
Governor / Director
Dovegate (2025)
The Board recommends that the Director remains vigilant of staff complacency and take measures to minimise it.
Governor / Director
Noted
Maidstone (2020)
Support local managers to reduce staff absence (see paragraph 3.7).
HMPPS
Implemented
Durham (2021)
The Board is concerned that prisoners are working as cleaners before checks are completed and they are not receiving back-pay (5.3.10).
Governor / Director
Brixton (2021)
The introduction of the offender flow process has resulted in men who do not meet the profile being sent to Brixton which is not equipped to support men very recently convicted, or those who have not been in a training prison, or men with substantial sentences still to serve. The process is setting up both these prisoners and the prison …
HMPPS
In Progress
Health investigations(101)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (x)
The Trust and Council should undertake an audit of the process of care co ordination with a view to establishing that suitable professionals are being assigned to service users on Enhanced CPA and that co-ordination is being effectively carried out in accordance with the current Practice Guidelines.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (ii)
The Trust and Council should ensure that assessments are undertaken by mental health professionals who are sufficiently qualified and experienced to be able to perform the task in a competent manner.
london
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
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
Restricted patients should be seen by a consultant psychiatrist acting as psychiatric supervisor. If seen by a specialist registrar there should be regular, recorded consultant supervision.
south_east
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (vi)
The Trust should undertake a review of the process of appointment of key workers and should not permit a junior psychiatrist to undertake the role of key worker for a patient unless the Care Plan is straightforward, short term and does not necessitate the involvement of other professionals.
london
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.3.1
The Mental Health Division should identify the competencies that it expects in RMOs caring for restricted patients. It should do this in consultation with Medical Directors of Health Boards and the relevant sections of the Royal College of Psychiatrists. The Division should seek reassurance from Health Boards caring for restricted …
scotland
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.1.10
The Health Board should consider making the conclusions of this report known to the locum RMO’s present employer, so that it can consider whether to audit his work in respect of restricted patients.
scotland
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Any social services worker assigned the task of social supervisor of a restricted patient should be an Approved Social Worker.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
In-patient units whose patients include offenders with disturbed personalities should have access to specialist psychodynamic expertise.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The third category member of the Mental Health Review Tribunal should be named 'other relevant discipline' and the Lord Chancellor's list should include a number of psychologists.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Efforts should be made to ensure that the medical members of tribunals dealing with restricted patients are forensic psychiatrists.
east_of_england
Independent investigation: Michael Kahan, Manchester (2008) — Rec 6
The Trust lone worker policy should be reviewed with immediate effect to ensure: that risks to workers are taken into account in the allocation of care coordinators.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.i.b
The Medical Director will need to focus carefully on the appraisal of all the medical staff in Bury. In our view this means that the Medical Director will need to do all of the annual appraisals, for all of the medical staff, until he is satisfied that the Associate Medical …
north_west
Independent investigation: George Bowley (Mr A), Bradford (2000) — Rec 15.4
If a dedicated community team is to continue to form part of the forensic service, the Trust and the service commissioners should satisfy themselves that it is capable of providing a comprehensive service and of meeting the standards expected of such a team. In particular, they should ensure that: o …
north_east_yorkshire
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 3
Where it is not possible to fill consultant posts with adequately qualified and otherwise suitable psychiatrists, locums and others acting as consultants should receive regular and recorded supervision under the oversight of the medical director.
south_east
Independent investigation: Remy Surage (Mr S), Orpington, Kent (1998) — Rec 7.9.1
Where health bodies have to continue employing doctors under extended locum arrangements they should put in place an appropriate individual support plan for each situation in which a doctor is not fully trained for the position they occupy. These arrangements should be part of the medical appraisal system, be monitored …
south_east
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 14
A clinician providing a second opinion should be of a similar or higher competency level than the referring clinician. (DB)
london
Independent investigation: Nicole TownshendJane Malkin, Leicester (2007) — Rec 7
The managers of LPT’s crisis resolution and home treatment service must map out the core and specialist knowledge, skills and competencies required of mental health professionals working within the service and ensure that all of its staff meet these competencies. What has not been evidenced in LPT is any formal …
midlands
Independent investigation: Nicholas Windsor, Northampton (2006) — Rec R2
Those staff with a role to play in the MAPPA system should have this identified in their job descriptions which in turn should be subject to supervision and review
midlands
Independent investigation: Lidie Diema, Beckton (1994) — Rec 5
We recommend that steps be taken to establish standards of minimum competence for interpreting staff ensuring not only competence in the relevant foreign language but also a high degree of familiarity with the English language. There is a need for the clear identification of the competencies necessary for someone to …
london
Independent investigation: Lidie Diema, Beckton (1994) — Rec 4
We reconm1end that, whilst the system of using in-house interpreters can and should continue, some steps have to be taken (i) to ensure the minimum competence of such interpreters both in English and the relevant foreign language and (ii) to ensure that the best interpreter (both in terms of language …
london
Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005) — Rec 27
DHSSPS in co-operation with responsible Departments in Great Britain should implement its commitment to the statutory registration and regulation of psychotherapists and counsellors as outlined in the 2006 consultation on standards. The associated guidance to psychotherapists and counsellors should aim to improve communication between statutory services and private counselling services, …
northern_ireland
Independent investigation: Keziah Flux Edmonds, East Cowes, IoW (2016) — Rec 6
As part of all primary and secondary mental health practitioners and service /operational managers’ recruitment interviews the interviewee should be asked to demonstrate how the Think Family Agenda underpins their practice.
south_east
Independent investigation: Keith Drummond, Perivale (2010) — Rec R2
The trust and local authority must ensure that their human resources policies include processes setting out how immediate action can be taken to deal with clinical or social work staff who are reported as posing a risk to patient/client safety. This may include re-allocation to a non-patient/client contact area, restriction …
london
Independent investigation: Kasey Gordon, Tottenham (2011) — Rec 10
The Trust must ensure that CCs, with appropriate support and clear managerial direction, follow the professional requirements of their role, and that a system is put in place to measure compliance with this.
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R6
If consultant psychiatrist A is not approved as a trainer for junior doctors, he should receive alternative ward-based medical support to help him manage his allocated inpatients.
london
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R2
The trust should ensure that managers who allocate roles under the CPA are aware of risks to staff and ensure that appropriate allocation takes place where gender is an issue (A).
midlands
Independent investigation: Jayne Poppy, Leigh on Sea (2002) — Rec 100
We recommend that the Authority seeks assurances from the Trust that the contractual position of Community Psychiatric Nurses of CPN2's grade is such that they are not expected to work autonomously in circumstances where they have concerns about their personal safety.
east_of_england
Independent investigation: Eric Daggers, Croydon (2005) — Rec 14
A clinician providing a second opinion should be of a similar or higher competency level than the referring clinician. (DB)
london
Independent investigation: Edward Miles, Tower Hamlets (2003) — Rec 11
The Trust must take immediate steps to address the issues identified regarding Doctor Falkowski's clinical practice, including his engagement with community teams, supervision of junior staff, and decision-making processes. This should involve a formal review of his practice, appropriate support and supervision, and, if necessary, disciplinary action. The Trust must …
london
Independent investigation: Dorothy Shepherd, Winchcombe (2010) — Rec 1
The Trust should carry out a review of all service users on CPA to ensure that their Care Co-ordinator has the appropriate qualification, skills and experience to take responsibility for the management of their case.
south_west
Independent investigation: Carmelita Tulloch, Vauxhall, London (2006) — Rec Recommendation Numbe
The Trust’s Human Resources department should have in place a system of identifying transferable qualifications of overseas trained psychologists and ensure that qualifications, skills and experience are commensurate with current United Kingdom requirements.
london
Independent investigation: Joe Lewis, Brighton (2014) — Rec 11
The Trust must ensure that when there are concerns about the practice of any staff member that appropriate action is taken in accordance with the Disciplinary Policy and Procedure.
south_east
Independent investigation: Jenny Foote, Acton (2015) — Rec 5
The Trust must ensure that it has a robust process for checking that all staff are appropriately registered with their professional body, and this should include ensuring that any agency staff employed are appropriately registered.
london
The Christie NHS Foundation Trust Rapid Review: Published November 2021 — Rec 2.2.10.3
The Board of Directors should be clear in its zero tolerance of poor behaviours anywhere in the organisation.
Christie NHS Foundation Trust
north_west
Investigation into matters relating to Jimmy Savile at Broadmoor Hospital — Rec (9)
We believe that stories of multiple sexual relationships between senior and junior staff circulated widely within and outside Broadmoor, and were particularly corrosive. We believe this contributed to an atmosphere that was unusually tolerant of sexual relationships between staff and patients in some parts of the hospital. We recommend that …
West London Mental Health NHS Trust
london
Investigation into matters relating to Jimmy Savile at Broadmoor Hospital — Rec (2)
Some celebrities may have the necessary qualities and the desire to contribute to the NHS in a non-executive capacity, but they should not be exempt from the usual selection process, which would include careful consideration of the benefits and risks. Celebrities should not be considered for operational or executive NHS …
West London Mental Health NHS Trust
london
Investigation into matters relating to Jimmy Savile at Broadmoor Hospital — Rec (1)
Many celebrities make a significant contribution to improving patient wellbeing and help to raise charitable funds, but that does not imply that they should be exempt from standard procedures governing access to NHS patients. NHS bodies should ensure that any celebrity they may consider appointing should be subject to the …
West London Mental Health NHS Trust
london
Independent review into treatment and care provided by 2Gether NHS … — Rec 2
The second recommendation is for the Trust to review the structure of the staffing arrangements to ensure that an appropriate balance of trained and untrained, senior and junior staff is available to deliver the best quality of safe care in what is a very challenging environment. We will follow this …
X’ was an inpatient at 2Gether NHS Mental Health Foundation Trust. The 2Gether NHS Foundation Trust
south_west
Independent investigation into the care and treatment of Mr Z: … — Rec 3
The Trust should review how it monitors and audits fitness to practice for those engaged in Psychological and Psychotherapy Services in relation to: safeguarding; abuse; PTSD treatment and risk methodologies.
Manchester Mental Health and Social Care NHS Trust
north_west
Assurance Review: Trust recommendations — Rec 47
Appraisals for medical staff (Link to R40) • Appraisals may identify colleagues who are having difficulties and a protocol should be put in place to safeguard staff when concerns are apparent. • The Responsible Officer should explicitly monitor appraisals which may demonstrate team dysfunction as a means of early warning …
north_west
An Independent Review into the care and treatment provided by … — Rec 11
NHS England must review and clarify the role of the Greater Manchester Adult Secure (Northwest) provider collaborative and the governance structures needed to oversee this role. The responsibilities of the collaborative need to be discharged by staff with the right experience and expertise. In light of the concerns identified in …
Greater Manchester Mental Health NHS Foundation Trust
north_west
An Assurance Review of the Independent Review into the care … — Rec 11
NHS England must review and clarify the role of the GM Adult Secure (Northwest) provider collaborative and the governance structures needed to oversee this role. The responsibilities of the collaborative need to be discharged by staff with the right experience and expertise. In light of the concerns identified in this …
Greater Manchester Mental Health NHS Foundation Trust
north_west
This Independent Investigation into concerns and issues raised relating to … — Rec 26
The Trust Board should ensure that there is a clear and explicit recognition of the Responsible Officer (RO) role and its duties, and that the RO is formally appointed, supported, and held accountable for the effective implementation of medical revalidation and fitness to practice processes.
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
Independent investigation: Alan Riddock, Bristol (2008) — Rec 5
The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that all clinical staff, including locum staff, receive a timely induction and that supervision and consultation arrangements are in place from the time they begin to deliver clinical services.
south_west
Independent investigation report into the care and treatment of Yusuf — Rec 3
Medical staffing levels were below expected levels on the night of 15 November. • The Trust should assess medical and nursing staffing levels in the paediatric UECC overnight to ensure capacity meets demand. This should include the number of clinicians, their seniority and their level of paediatric experience. • The …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.2.2
Social workers supervising conditionally discharged patients must be Mental Health Officers. The Social Work Department must ensure that these social workers have the necessary competencies and training to carry out their supervisory function. In the Inquiry’s view, this includes mental state and risk assessment skills, as well as generic social …
scotland
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Arrangements for psychiatric training both nationally and locally in Suffolk and in the Anglia and Oxford Region, should be reviewed and, if necessary, enhanced so as to ensure that all trainees in general psychiatry receive adequate clinical training, and experience in psychodynamic and forensic aspects of psychiatry.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
General Psychiatrists taking up consultant posts with responsibility for secure beds should have had a period of training in forensic psychiatry.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
All trainees in General Psychiatry should spend a period of training in a forensic psychiatric service under the supervision of a Forensic Psychiatrist.
east_of_england
Scottish Fatal Accident Inquiries(5)
Raymond James Birse
There are high risks involved in dismantling buildings and structures, and in this instance, the structure was over 45 years of age. There is merit in the HSE inspector’s observation that such a potentially dangerous activity should only be undertaken by contractors with expertise in this type of work. The system that was adopted by Mr Birse on the day …
Sep 2007
Marlene Patricia Wightman
That all nursing staff recruited in the Hospital to care for post-operative breast surgery patients should either (i) have sufficient prior experience in caring for surgical patients as to be familiar with the nature and extent of the particular procedures which have been carried out on these patients, have knowledge of the detailed requirements of their care, be aware of …
Nov 2009
Andrezej Freitag
I urge that there be improvements in the certification of competent staff and the policing of health and safety legislation.
Apr 2010
John Andrew McCafferty
I would have thought that serious consideration should be given by anyone owning a caravan to having such a device installed. I would have thought that the same regulations that apply to other caravans and homes should apply to touring caravans to try and ensure that persons working on gas appliances in touring caravans are Corgi registered. I would have …
Mar 2009
Harry McKenzie
(Fifty eight) A reasonable precaution, whereby the death of Mr. McKenzie might have been avoided, would have been the wearing of the seatbelt by himself, as the driver of the lorry concerned. To comply with this precaution would only require the driver of the lorry to use the seatbelt already fitted within the lorry. Accordingly, notwithstanding current practice, HGV Drivers …
Dec 2008
Article 2 learning points(1)
Detention investigations(9)
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 55
relevant experience in either custodial management or contract management be a requirement for the post.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 26
I recommend that Officers B and C’s status is checked and that their accreditation be withdrawn if this has not already happened.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 4
I recommend that Securicor draws my views to the attention of those officers still employed who were responsible for taping the detainee's skirt together between her legs, and considers what further action may be required.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R16
The SMT and DCMs at Brook House must ensure that all staff are subject to an effective annual appraisal process that results in identifying and addressing training and other developmental needs. (To be completed within 3 months)
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 25
arrangements are introduced to prohibit the staff of removal centres and escort contractors from membership of racist organisations.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 25
I recommend that a protocol is drawn up between GSL and IND specifying the qualities necessary for DCOs allocated to the DDU. Any officers so allocated should have enhanced interpersonal skills and training, and their integrity must be beyond doubt.
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
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
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R3
Serco should consider with the Home Office the development of suitability criteria for the detention of time-served foreign national offenders at Yarl’s Wood.
Immigration Detention
Independent reviews(50)
Building Control Independent Panel — Rec 18
Establish a single professional code of conduct for all BCAs, setting expectations for independence, behaviour and public interest standards across the sector.
Building Safety
Building Control Independent Panel — Rec 15
Reform registration and revalidation to support competence without excessive burden. Shift towards CPD based, predictable and harmonised assessment processes that retain experienced inspectors.
Building Safety
Graham Pre-pack Review — Rec 5
SIP16 be amended to the effect that valuations must be carried out by a valuer who holds professional indemnity insurance.
Other
Newman CAA Review — Rec 5.1
The skill requirements of the board should be reviewed to reflect the changing needs of the organisation and inform NED appointment decisions. As a minimum, in addition to the existing range of skills, the board should include NEDs with significant experience of working in a consumer-facing business and experience in …
Other
Pickles Electoral Fraud Review — Rec R47
Officers at the most senior level in a local authority, such as Chief Executives and Heads of Paid Service, should be appointed as Electoral Registration Officers and Returning Officers and should undertake relevant training to ensure that they have the skills required for the roles.
Other
Hodgson Charities Act Review — Rec 18
The Government should consider if and how to widen the types of criminal offences disqualifying individuals from charity trusteeship, taking into account the need to support rehabilitation of former offenders.
Other
Litchfield WCA Review Year 4 — Rec 33
Review the terms of reference, role profile and job description of the HAA with input from a senior occupational health professional to maximise the value of the position.
Employment & Work
Litchfield WCA Review Year 4 — Rec 28
The Department strengthen its requirements for HCPs working on the contract to have suitable and sufficient previous experience of dealing with people with mental health problems so that they can contextualise their findings at assessment.
Employment & Work
Keogh Cosmetic Interventions Review — Rec 13
'Independent healthcare providers should only allow practising privileges to those cosmetic surgeons who can demonstrate that they have achieved and are able to maintain competence in the procedures which they offer'.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 8
Entry to the register should be subject to: • achievement of accredited qualification • premises meeting certain requirements • adherence to a code of practice that covers handling complaints and redress, insurance requirements, responsible advertising practice and consent practices • continued demonstration of competence through an annual appraisal.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 2
The RCS Interspecialty Committee should work with the CQC and the new Chief Inspector of Hospitals to ensure that providers follow the standards developed. In the meantime, the Review Committee recommend that only doctors on a GMC Specialist Register should perform cosmetic surgery, and that those doctors should work within …
Health & Social Care
Myners Institutional Investment Review — Rec 1
Effective decision-making: Decisions should be taken only by persons or organisations with the skills, information and resources necessary to take them effectively. Where trustees elect to take investment decisions, they must have sufficient expertise to be able to evaluate critically any advice they take. Trustees should ensure that they have …
Other
Greenaway Shape of Training Review — Rec 5
Full registration should move to the point of graduation from medical school, subject to the necessary legislation being approved by Parliament and educational, legal and regulatory measures are in place to assure patients and employers that doctors are fit to practice.
Health & Social Care
Greenaway Shape of Training Review — Rec 4
Medical schools, along with other appropriate organisations, must make sure medical graduates at the point of registration can work safely in a clinical role suitable to their competence level, and have experience of and insight into patient needs.
Health & Social Care
Winsor Review Part 2 — Rec 82
Forced distribution should be used to identify the least effective 10% of officers and staff. The forced distribution should be decided upon in moderation panels. Line managers of officers and staff who are the least effective 10% of performers must consider the use of unsatisfactory performance procedures for officers and …
Policing & Security
Winsor Review Part 2 — Rec 81
The amended NPIA PDR should be used in all forces in England and Wales beginning in 2014/15. Training should be given in advance to all line managers to ensure that they can use the PDR efficiently and effectively, so as to inspire confidence in the system and its operation.
Policing & Security
Winsor Review Part 2 — Rec 80
The amended NPIA PDR template, and its accompanying guidance, should be established as the minimum standard for appraisal in the police service. Forces should be at liberty to develop and improve the PDR system thus established, but they should not disturb or eliminate its essential features. Forces should abide by …
Policing & Security
Winsor Review Part 2 — Rec 79
The Police Professional Body should amend the current NPIA PDR model to make it fit for use as the basis of contribution-related pay in the police service. This will involve: (a) reducing the number of box markings to three and giving clear definitions of each; (b) taking account of continuous …
Policing & Security
Winsor Review Part 2 — Rec 44
A future police pension scheme should retain the existing test which must be fulfilled for an officer to be considered for an ill-health retirement pension, that is that the officer should be permanently disabled for the ordinary duties of a police officer.
Policing & Security
Winsor Review Part 2 — Rec 41
A returning officer should have an unblemished disciplinary record and be able to pass the fitness test. Forces should also assess carefully a record of poor attendance. Such former officers should be on probation for six months.
Policing & Security
Winsor Review Part 2 — Rec 40
A former officer who resigns to take a police staff job or who is dismissed on the grounds of incapability or poor attendance following the restricted duty process, should be entitled to be considered for re-appointment if, following an assessment by an approved medical practitioner, the condition which previously compromised …
Policing & Security
Winsor Review Part 2 — Rec 39
From September 2014, officers on restricted duty should have their deployability and capability to exercise police powers assessed one year after being placed on restricted duty. Officers who are not deployable and are not capable of work which requires the office of constable should sustain a reduction in pay equal …
Policing & Security
Winsor Review Part 2 — Rec 38
The Police Regulations 2003 should be amended to specify the procedure for determining the circumstances in which an officer may be placed on restricted duty, the arrangements which a Chief Constable may make for officers on restricted duty, and the adjustments to the pay of such officers.
Policing & Security
Winsor Review Part 2 — Rec 37
From September 2018, national fitness tests for specialist police officer roles should be introduced, designed most closely to test the physical capability of officers to discharge the responsibilities of the specialist police officers in the field.
Policing & Security
Winsor Review Part 2 — Rec 36
From September 2018, probationers should have to prove their fitness against the more demanding physical assessment test of the Police Service of Northern Ireland.
Policing & Security
Winsor Review Part 2 — Rec 35
From September 2018, the national police recruitment test should be replaced by the more demanding physical assessment test used in the Police Service of Northern Ireland.
Policing & Security
Winsor Review Part 2 — Rec 34
From September 2018, an annual physical fitness test should be introduced for all police officers in England and Wales, equivalent to the test used for recruits in the Police Service of Northern Ireland.
Policing & Security
Winsor Review Part 2 — Rec 33
A fitness test should be introduced in September 2013 for all police officers and staff required to undertake personal safety training. Participants should be required to attain level 5:4 on a 15-metre shuttle run. From September 2014, those who fail the test three times should be subject to the appropriate …
Policing & Security
Winsor Review Part 2 — Rec 31
For each rank above constable, a core set of leadership, management and financing skills should be established by the new Police Professional Body. An officer should be trained and assessed in these before he is promoted.
Policing & Security
Winsor Review Part 2 — Rec 27
The sole criterion for the recruitment, advancement and promotion of police officers should be merit.
Policing & Security
Winsor Review Part 2 — Rec 21
Determination Annex C of Regulation 12 of the Police Regulations 2003 should be amended to provide that those entering above the rank of constable should serve a probationary period in accordance with the applicable direct entry scheme.
Policing & Security
Winsor Review Part 2 — Rec 5
The passmark for the 2013 SEARCH assessment process should be raised to at least 70%. This should be reviewed after five years to ensure that the academic threshold is sufficiently rigorous.
Policing & Security
Winsor Review Part 2 — Rec 3
From April 2013, an additional qualification should be added to the list required for appointment to a police force in Regulation 10 of the Police Regulations 2003. Candidates eligible for appointment to a police force should have either a Level 3 qualification, or a police qualification which is recognised by …
Policing & Security
Heseltine Growth Review — Rec 7
In light of the new role and vision for LEPs, each LEP should ensure that their board has the necessary skills and expertise to deliver their expanded functions and pay particular attention to the representation of employees from both private and public sector.
Other
Cavendish Review — Rec 14
The Secretary of State for Health should commission the Professional Standards Authority for Health and Social Care for advice on how employers can be more effective in managing the dismissal of unsatisfactory staff, the legal framework around this, and the relationship with referrals to professional regulators.
Health & Social Care
Cavendish Review — Rec 6
Employers should be supported to test values, attitudes and aptitude for caring at recruitment stage. NHS Employers, HEE and the National Skills Academy for social care should report on progress, best practice and further action on their recruitment tool by summer 2014. Making Caring a Career
Health & Social Care
Cavendish Review — Rec 3
The Care Quality Commission should require healthcare assistants in health and support workers in social care to have completed the “Certificate of Fundamental Care” before they can work unsupervised.
Health & Social Care
Harris Review: Deaths in Custody — Rec 15
A new specialist role must be created to work specifically with all young adults in custody. The Custody and Rehabilitation Officer (CARO) will be required to take responsibility for the overall well-being of the young adult and must have a caseload of no more than fifteen or twenty prisoners, so …
Justice & Legal
Young Health & Safety Review — Rec 14
Where health and safety consultants are employed to carry out full health and safety risk assessments, only qualified consultants who are included on the web based directory should be used.
Other
Young Health & Safety Review — Rec 11
Professionalise health and safety consultants with a qualification requirement that all consultants should be accredited to professional bodies. Initially the HSE could take the lead in establishing the validation body for qualifications, working with the relevant sector and professional bodies. However, this function should be run by the professional bodies …
Other
Anderson Review — Rec 104
The Chief Commissioner should be a person of unquestioned professional distinction and independence, committed not only to leading the work of ISIC but to accounting publicly and to Parliament for that work, and to building public awareness of ISIC and its role. The Chief Judicial Commissioner should be eligible to …
Other
Laming Review (Baby P) — Rec 38
Ofsted, the Care Quality Commission, HMI Constabulary and HMI Probation should take immediate action to ensure their staff have the appropriate skills, expertise and capacity to inspect the safeguarding and child protection elements of frontline services. Those Ofsted Inspectors responsible for inspecting child protection should have direct experience of child …
Other
Laming Review (Baby P) — Rec 31
The General Social Care Council should review the Code of Practice for Social Workers and the employers' code ensuring the needs of children are paramount in both and that the employers' code provides for clear lines of accountability, quality supervision and support, and time for reflective practice. The employers' code …
Other
Laming Review (Baby P) — Rec 28
The Department for Children, Schools and Families, working with the Children's Workforce Development Council, General Social Care Council and partners should introduce a conversion qualification and English language test for internationally qualified children's social workers that ensures understanding of legislation, guidance and practice in England. Consideration should be given to …
Other
Laming Review (Baby P) — Rec 27
The Department for Children, Schools and Families and the Department for Innovation, Universities and Skills should introduce a fully-funded, practice-focused children's social work postgraduate qualification for experienced children's social workers, with an expectation they will complete the programme as soon as is practicable.
Other
Laming Review (Baby P) — Rec 26
The General Social Care Council, together with relevant government departments, should: work with higher education institutions and employers to raise the quality and consistency of social work degrees and strengthen their curriculums to provide high quality practical skills in children's social work; work with higher education institutions to reform the …
Other
Laming Review (Baby P) — Rec 16
The Department for Children, Schools and Families should revise Working Together to Safeguard Children to set out the elements of high quality supervision focused on case planning, constructive challenge and professional development.
Other
Laming Review (Baby P) — Rec 15
The Social Work Task Force should establish guidelines on guaranteed supervision time for social workers that may vary depending on experience.
Other
Laming Review (Baby P) — Rec 7
All Directors of Children's Services who do not have direct experience or background in safeguarding and child protection must appoint a senior manager within their team with the necessary skills and experience.
Other
Narey Review of Children's Residential Care — Rec 32
I recommend that the Department identify and promulgate best practice in recruitment to children's homes. That should include advice on how, as far as possible, employers can screen out those whose behaviour might fall short of the immense challenge that this work can present.
Other
PHSO casework decisions(3)
P-001694 — HCRG Care Group
Mrs O complained about unprofessional conduct and mistreatment of Mr A by a carer, including refusal to change an incontinence pad, and HCRG's failure to provide a male carer and dismiss family concerns.
NHS in England
Nov 2022
P-003829 — Sheffield Children's NHS Foundation Trust
Ms P complained about inadequate care for her son, W, under a consultant, including poor monitoring and incorrect central line insertion. She also raised concerns about staff communication and complaint handling.
NHS in England
Partly Upheld
Oct 2023
P-002564 — Lancashire Teaching Hospitals NHS Foundation Trust
A nurse misgendered her, acted aggressively, and removed her ear defenders without permission, causing anxiety and impacting her mental health.
NHS in England
Apr 2024
LGO / SPSO decisions(46)
PSOW-202502399 — Betsi Cadwaladr University Health Board
Mr C complained that Betsi Cadwaladr University Health Board withdrew an offer of a place on a training programme because it could not fund the Sponsorship Certificate that Mr C required. The Ombudsman found that the advert and recruitment pack had not made it clear that sponsorship was not available …
PSOW (Public Services Om…
Health
Oct 2025
24-022-201 — Stockton-on-Tees Borough Council
Summary: We will not investigate Mrs X’s complaint about the actions and behaviour of a support worker. This is because the complaint is not in our jurisdiction.
LGO (Local Government & …
Adult Care Services
Jun 2025
22-007-143 — Stockton-on-Tees Borough Council
Summary: We will not investigate this complaint about the Council’s conclusion that the complainant poses a risk to staff. This is because there is insufficient evidence of fault in how the Council dealt with the matter.
LGO (Local Government & …
Other Categories
Oct 2022
24-013-139 — Staffordshire County Council
Summary: Mr X and Mr Y complained about the Council’s biased and inaccurate information which led to its decision to remove their foster child from their care. They also complained about a lack of support and the Council withholding information. We do not find the Council was at fault.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jul 2025
201804797 — Edinburgh College
Mr C complained that the college's handling of his concerns about the behaviour of a learning support worker was unreasonable. We found that the college was aware of Mr C's support needs, how this affected him and had put in place reasonable support for him. We noted that two meetings …
SPSO (Scottish Public Se…
Education
Not Upheld
Mar 2020
21-011-656 — Aman Care Limited
Summary: We will not investigate this complaint about a carer. This is because the alleged harassment and stalking by a carer is best dealt with by the Police. And we have no remit to consider the carer’s employment with the care company.
LGO (Local Government & …
Adult Care Services
Jan 2022
21-007-679 — Barnsley Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s decision to end Mr and Mrs X’s approval as Shared Lives carers. That is because the complaint is late.
LGO (Local Government & …
Adult Care Services
Mar 2022
21-011-174 — Hales Group Ltd
Summary: Mr C complained that Hales Group Ltd was at fault for errors made in administering medication, for poor social care and for a failure to provide documents requested. Hales was at fault for failures in administering medicine and for a failure to provide Mr C with requested documents. Its …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2022
24-002-973 — London Borough of Sutton
Summary: We will not investigate Mrs X’s complaint about the Council not sourcing suitable carers for her when she needed help with showering. She says the carers did not hold enhanced disclosure and barring service clearance. This is because the complaint is late and there are no good reasons to …
LGO (Local Government & …
Adult Care Services
Oct 2024
24-008-885 — Norfolk County Council
Summary: Mr and Mrs X complain about a LADO investigation and the removal of a child they were fostering. There was no fault in the Council’s response to allegations by a child Mr and Mrs X fostered.
LGO (Local Government & …
Children S Care Services
Not Upheld
Apr 2025
25-000-505 — Hertfordshire County Council
Summary: We will not investigate this complaint about the alleged attitude of a social worker in taking three and a half days to make a phone call. The situation is unlikely to have been an emergency and there is not enough evidence of fault or injustice to warrant our further …
LGO (Local Government & …
Children S Care Services
Jun 2025
25-011-715 — Hereford & Worcester Fire & Rescue Service
Summary: We will not investigate this complaint that members of the Fire Service stalked him. Further investigation would not lead to a different outcome.
LGO (Local Government & …
Other Categories
Sep 2025
25-004-926 — London Borough of Lambeth
Summary: The Council was not at fault for refusing to pay Ms X its full fostering rate (including additional fees) from the date she became a kinship foster carer. This decision was in line with its policy – which says only fully approved foster carers get the full rate – …
LGO (Local Government & …
Children S Care Services
Upheld
Nov 2025
201502802 — Scottish Prison Service
Mr C complained that a member of prison staff had acted unreasonably by making a comment which he felt was discriminatory and constituted harassment. We carefully considered the information Mr C had provided and sought further information from the Scottish Prison Service (SPS), which included a copy of their investigation …
SPSO (Scottish Public Se…
Prisons
Upheld
Dec 2015
PSOW-202107843 — Gwynedd Council
The Ombudsman’s office received a complaint that a member (“the Member”) of Gwynedd Council (“the Council”) had breached the Code of Conduct. It was alleged that the Member had behaved inappropriately when she responded in German to correspondence she received in Welsh. The investigation considered whether the Member failed to …
PSOW (Public Services Om…
Local Government
Oct 2022
PSOW-202500170 — Carmarthenshire County Council
Miss X complained that Carmarthenshire County Council failed to respond to the complaint she submitted in February 2025 regarding the housing allocation and damp at the property. The Ombudsman found that the Council had not considered the complaint under its formal complaints procedure. The Ombudsman said this caused uncertainty and …
PSOW (Public Services Om…
Local Government
May 2025
PSOW-202410015 — Caerphilly County Borough Council
Ms A complained that Caerphilly County Borough Council had failed to respond to a verbal complaint she made in August 2024 regarding housing support. The Ombudsman decided that whilst the Council did return Ms As call to discuss her concerns, it was recorded as a service request rather than a …
PSOW (Public Services Om…
Local Government
May 2025
22-000-919 — Knowsley Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with an application for a private hire taxi licence. This is because further investigation would not lead to a different outcome.
LGO (Local Government & …
Environment And Regulation
May 2022
22-000-028 — Kent County Council
Summary: We will not investigate Mr X’s complaint about the actions of an Appropriate Adult who was allocated to advocate for him after he was arrested in October 2020. This is because an investigation by this office could not add to the responses previously provided by the provider and the …
LGO (Local Government & …
Adult Care Services
May 2022
22-003-783 — West Northamptonshire Council
Summary: We will not investigate this complaint about individual Council officers not being held to account for failings in an upheld complaint. Investigation would be unlikely to lead to a different outcome or achieve the remedy Mr X wants.
LGO (Local Government & …
Children S Care Services
Upheld
Jul 2022
21-012-864 — London Borough of Lewisham
Summary: Mr and Mrs X complain about the Council’s decision to end their arrangement to foster a child after five years causing distress and financial loss. We have found no evidence of fault in the way the Council considered these matters. So we are completing our investigation.
LGO (Local Government & …
Children S Care Services
Not Upheld
Jul 2022
21-012-055 — Oldham Metropolitan Borough Council
Summary: The complainant (Mr X) complained about the way the Council recorded information about him in his social care files and about the conduct of his previous Social Worker. He also complained about other social care staff, saying they discriminated against him. We discontinue this investigation as for some issues …
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
22-011-130 — Essex County Council
Summary: We will not investigate this complaint about the Council’s response to the complainant’s representations about the content of a report. This is because we can achieve nothing significant by doing so.
LGO (Local Government & …
Children S Care Services
Dec 2022
24-001-176 — Rochdale Metropolitan Borough Council
Summary: We will not investigate this complaint alleging the Council breached the terms of a licence agreement for a commercial property. It is not our role to adjudicate on disputed points of law. It is reasonable to expect the complainant to take the matter to court.
LGO (Local Government & …
Environment And Regulation
Jun 2024
23-010-618 — Peterborough City Council
Summary: We found fault by the Council on Mrs D’s complaint about how she was dealt with following allegations from her foster child. Concerns were not consistently raised with her, a serious allegation was not properly dealt with, there was a failure to follow procedures, and she was not given …
LGO (Local Government & …
Children S Care Services
Upheld
Jun 2024
24-007-466 — Redcar & Cleveland Council
Summary: We will not exercise discretion to investigate this complaint about the Council’s support of allegations about Mr X by its tenant in 2022. This complaint which was received outside the normal 12-month period for investigating complaints. There is no evidence to suggest that Mr X could not have complained …
LGO (Local Government & …
Other Categories
Sep 2024
24-009-950 — Suffolk County Council
Summary: We will not investigate this complaint that the complainant was unfairly banned from working as a taxi driver on under the Councils’ home to school transport contract. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Environment And Regulation
Sep 2024
24-015-556 — London Borough of Ealing
Summary: We will not investigate this complaint about the conduct of a social worker. That is because the complaint is late.
LGO (Local Government & …
Adult Care Services
May 2025
24-022-314 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s decision not to provide Mrs X’s son with free transport to school. This is because there is not enough evidence of fault.
LGO (Local Government & …
Education
Jun 2025
24-010-932 — North Northamptonshire Council
Summary: Mrs X complained that the Council failed to properly consider all the relevant information when she appealed its decision to deny school transport assistance for her son Y. She said the decision has had significant negative impacts; causing anxiety, stress and logistical challenges for Y and the family. We …
LGO (Local Government & …
Education
Not Upheld
Jun 2025
24-022-812 — Brighton & Hove City Council
Summary: We will not investigate this complaint that the Council has failed to reassess the complainant’s son’s Education Health and Care plan within the statutory timescale. This is because the complainant has used her right to appeal to the First-tier Tribunal (Special Educational Needs and Disability), and the complaint is …
LGO (Local Government & …
Education
Jun 2025
24-022-665 — Surrey County Council
Summary: We will not investigate this complaint about the Council’s decision to remove provision from the complainant’s son’s Education Health and Care plan. This is because the complainant has the right to appeal to the First-tier Tribunal (Special Educational Needs and Disability) and it would be reasonable for her to …
LGO (Local Government & …
Education
Jun 2025
24-022-547 — Sefton Metropolitan Borough Council
Summary: We will not investigate this complaint about the Council’s decision to refuse the complainant’s application and appeal for school transport assistance for her son. There is insufficient evidence of fault on the Council’s part to warrant our intervention.
LGO (Local Government & …
Education
Jun 2025
24-016-280 — Buckinghamshire Council
Summary: We will not investigate Miss X’s complaint about the Council not authorising a school place offered to her daughter, or naming that school in her daughter’s Education, Health and Care Plan. This is because she has already used her right of appeal at Tribunal.
LGO (Local Government & …
Education
Upheld
Jun 2025
25-003-801 — Kent County Council
Summary: We will not investigate Mr X’s complaint about an unsuccessful appeal for a school place. This is because an investigation would be unlikely to find fault.
LGO (Local Government & …
Education
Jun 2025
24-020-806 — Suffolk County Council
the Council’s decision to refuse the complainant’s application and appeal for school transport for her son. There is
LGO (Local Government & …
Education
Jun 2025
25-000-800 — Cambridge City Council
Summary: We will not investigate this complaint about taxi licensing. This is because the complaint is late, there is not enough evidence of fault to justify investigating and any injustice is not significant enough to justify our involvement.
LGO (Local Government & …
Environment And Regulation
Jun 2025
25-016-478 — Dudley Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint about the unlicensed sale of alcohol, allegations of abuse against a relative, and the alleged criminal behaviour of a person he knows. This is because parts of his complaints are late and there is not enough evidence of fault in the Council’s …
LGO (Local Government & …
Other Categories
Nov 2025
201101605 — Scottish Prison Service
Mr C complained that the SPS had failed to properly and fairly investigate a confidential complaint, which he had submitted to the governor. Our investigation found that the matter had been fully investigated and appropriate action taken as a result. Related reading View Decision Report 201101605 as a PDF (13.2 …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2011
201205112 — Scottish Prison Service
Mr C, who is a prisoner, complained that he was subjected to discriminatory abuse by a fellow prisoner. Our investigation considered the steps that the Scottish Prison Service (SPS) took to deal with the abuse, and we were satisfied they were reasonable in the circumstances. There was no evidence that …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Jun 2013
201602142 — New College Lanarkshire
Miss C complained that college staff did not take action to prevent her from being subjected to inappropriate behaviour from other students on her course. We found that the college had taken reasonable action in line with their policy and procedures when Miss C had experienced difficulties with other students …
SPSO (Scottish Public Se…
Education
Not Upheld
Jun 2017
22-005-194 — Wirral Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint that the financial remedy offered by the Council is not enough. That is because further investigation will not lead to a different outcome.
LGO (Local Government & …
Children S Care Services
Upheld
Aug 2022
22-005-482 — Lancashire County Council
Summary: We will not investigate this complaint about what happened during a wedding. This is because there is not enough evidence of fault by the Council or injustice to the complainant. It is unlikely we could add anything to the Council’s response.
LGO (Local Government & …
Other Categories
Sep 2022
23-017-538 — Luton Borough Council
Summary: We will not investigate Mr X’s complaint about matters relating to his employment. This is because the Council is not Mr X’s employer and an investigation by this office would not be able to add to the response the Council has already provided on this matter.
LGO (Local Government & …
Children S Care Services
Apr 2024
24-013-196 — Manchester City Council
Summary: We will not investigate this complaint about how the Council dealt with a complaint about the conduct of a councillor. This is because we are unlikely to find fault.
LGO (Local Government & …
Other Categories
Nov 2024
24-011-483 — Transport for London
Summary: We will not investigate this complaint about the Authority’s staff because the courts and insurers are better placed to consider the complaint.
LGO (Local Government & …
Transport And Highways
Nov 2024
Domestic Homicide Reviews(42)
Cheltenham — recommendation 4E
Raise awareness that social care cases are not allocated to student social workers and all professionals need to engage with the allocated social worker. The allocated social worker must ensure that they have proper oversight over the case i.e. engaging with the family.
Children’s Social Care
Wiltshire — recommendation R55
Action is taken in relation to the individual social workers practice.
Children’s Social Care
Buckinghamshire — recommendation Oxford Health Recomm
The Trust is to inform the Agency Worker, who no longer works at the Trust, that some aspects of his work fell below the Trust’s expected standards, and the Trust will inform the agency through which he was employed.
Oxford Health
Oxford Health NHS Foundation …
Wiltshire — recommendation 4
SWITCH Staff needs to be adequately trained to identify and deal with RISK and the strategic lead in force needs to ensure that staff has the requisite skills. Consideration should be given by the police to adopt a tenure policy for SWITCH police staff in line with the Wiltshire Probation …
Swindon & Wiltshire Integrated Targets for …
Wiltshire Police
Tendring — recommendation 4
The GP surgery should have a clear role descriptor in place for the role of the practice matron. Ensuring the role is supported to work collaboratively with both internal and external agencies, is patient focused and supports holistic assessment.
Anglian Community Enterprise
Anglian Community Enterprise
Sefton — recommendation 10
The Trust should ensure that newly qualified staff are afforded the correct level of caseload protection .
Merseyside Probation Trust
Probation Service
Northumberland — recommendation 3
A clinical review of a sample of x cases of children, who are seen within the ADHD clinic and have additional needs that require Care Co-ordination have a care co-ordinator who has the skills to meet their needs.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
East Sussex — recommendation KSSCRC3
KSS CRC to ensure that the competencies of temporary and/or agency staff are checked.
Kent Surrey and Sussex Community Rehabilitation …
Essex Community Rehabilitation Company
Basildon — recommendation 11.7.4
That where an offender is within MAPPA, responsibility for applications for Violent Offender Orders (VOO), and similar civil protective orders, should sit with specialist staff within Management of Sexual and Violent Offenders (MOSOVO). MOSOVO staff should take the lead in liaising with Essex Police Legal Department and applying for such …
Essex Police
Essex Police
Manchester — recommendation 8.6
For Greater Manchester Integrated Care Board to explore the issue of background checks for persons providing care on an informal or unregulated basis, to amend policy where appropriate and to incorporate into continuing professional development.
Greater Manchester Integrated Care Board
NHS Greater Manchester ICB
Cheltenham — recommendation GASC.4
Where individuals are reluctant to engage with Registered Social Workers specifically, alternative social care practitioners may provide support to the individual under the direction of an appropriately qualified lead worker.
Gloucestershire Adult Social Care
Norfolk — recommendation G
A review will be undertaken of our Succession Application form as to the information gathered and whether this needs to include more about the applicant’s history.
L&Q Housing Association
Lincoln — recommendation 10.4.5
Adult Care should ensure that effective measures are in place to determine the nature and complexity of cases and ensure that cases are allocated to staff with the appropriate experience and skills to manage them.
Lincolnshire County Council Adult Care
Lincoln — recommendation 10.3.2
Addaction to formally establish staff confidences and competences relative to identification and recognition of domestic abuse and the appropriate response to such incidents.
Addaction
Durham — recommendation 5b
Before the decision to return any weapons is made, full recorded checks are undertaken both internally and externally, to determine the fitness of the licence holder to return the weapons and certificates to.
Durham Constabulary
Durham Constabulary
Wiltshire — recommendation 2
A need for a common risk assessment to include on the referral any history of violence and/or alcohol fuelled behaviour. This would enable staff to refine the scope of interventions/support a client requires whilst improving staff safety.
Wiltshire Council Substance Misuse Commissioning Team
Wiltshire — recommendation 3
NHS Wiltshire will explore how to develop a violent patient programme which would support patients who are known to have abusive behaviour.
NHS Wiltshire
NHS Bath and North …
Wiltshire — recommendation 5
To review its “Lone Working” procedure on an annual bases and ensure all new staff are aware of the procedure at induction
Community4
Wiltshire — recommendation 2
An appropriate member of the Community4 team in the North and West to attend partnership agency meetings (ASBRAC, MARAC, SWITCH) as a method of joined up working and for sharing information relating to the risk to Community 4 workers and partnership agencies alike.
Community4
Wiltshire — recommendation 1
The wording of its Strategic Agreement to Share Information to include that signatory organisations know the 7 golden rules for information sharing and in particular understand that information can be shared to prevent harm to an individual and third parties including front line staff.
Wiltshire Assembly’s Public Services Board
Lincoln — recommendation 3
To review the process for assessing housing applicant’s medical need and ensure those staff making the assessments are competent. Waterloo have already been contacted about this.
ELDC
Lincoln — recommendation 1
Ensure Waterloo Housing group are complying with the housing register contract including ensuring their staff are competent to identify and report safeguarding concerns and have appropriate policies.
ELDC
Northampton — recommendation 5
An investigation will be undertaken regards Support Worker VJ for not taking the appropriate action when the victim called to say he was unsafe in September 2015. The resulting action taken will depend on whether through the DHR it can be ascertained had the Support Worker called the police, whether …
Northampton Partnership Housing
South Staffordshire — recommendation 12.2
That the Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning and Development Board should promote professional awareness of the influence and pressure that can be exerted when professionals and subjects reside in close proximity and particularly within small communities through domestic abuse training provision and in connection with publication of this Review.
Staffordshire and Stoke-on-Trent Domestic Abuse Commissioning …
Doncaster — recommendation 3
Knowledge of domestic abuse issues should become a contractual obligation for care providers.
Safer Doncaster Community Safety Partnership
Croydon — recommendation CCG_IMR_6
The practice should identify a DASV Lead
Croydon Clinical Commissioning Group
Croydon Clinical Commissioning Group
Croydon — recommendation 30
Ensure when appointed that the Lead GP for safeguarding has domestic violence included in their job description.
NHS England
NHS England
Northumberland — recommendation 4
Specialist Care Triumvirate Management Team should further review the clinical practice of those individuals identified by the Investigating Officer and clinical advisors to ensure that the early interventions already initiated in the process of undertaken the review are sufficiently robust to ensure patient safety.
Northumberland Tyne and Wear NHS Foundation …
Cumbria, Northumberland, Tyne and …
South Worcestershire — recommendation 21
An induction process is developed and implemented for new staff that ensures specific skills and knowledge appropriate to role and duties are identified and that progress is recorded.
Adult Social Care, Worcestershire County Council
South Worcestershire — recommendation 2
Improve practitioners understanding of, and competence in responding to adults who are experiencing or at risk of abuse.
South Worcestershire Community Safety Partnership
Basildon — recommendation 11.7.5
That a dedicated cohort of staff should be identified and provided with training in the management of violent offenders and legislation relating to protective orders: they should then lead in this area.
Essex Police
Essex Police
Doncaster — recommendation 19.2.7
Appointment of an Independent role within parishes, for cases when it is identified that the Safeguarding Officer is also the clergy’s spouse and there is a potential conflict of interest.
Sheffield Diocese
Hackney — recommendation 3
The MPS should review its Human Resources support system to ensure that a report of staff absence in a CSU through work-related stress will prompt an immediate review of the officer’s work file on CRIS and clear accountability transferred and monitored by the next level of supervision until return to …
Metropolitan Police Service
Metropolitan Police Service
South Ribble — recommendation None
Safety of practitioners when lone working.
Chorley and South Ribble ICB
Southend-on-Sea — recommendation 36
A system of regular clinical supervision for all IDVA staff who carry caseloads should be in place separate from their caseload and personal development supervision.
Victim Support | Safer Places
Fenland — recommendation 5
The FCSP should contact the Safeguarding board to satisfy itself on the level of checking carried out on paid carers. It is important to stress that the perpetrator in this case was in a relationship with Laraine and was not in receipt of funding for the care he provided for …
Fenland Community Safety Partnership
Castle Point — recommendation 8
It is recommended that the Local Authority review its MAPPA representation and consider making MAPPA attendance part of the community safety manager role with the community safety officer as deputy in their absence.
Castle Point Borough Council
Castle Point Borough Council
Northampton — recommendation 4.2.3.5
This recommendation is suggested in order to reduce the impact on those that have to manage the individuals and to prevent or reduce the automatic placement of personnel into departments that can take place without knowledge of wider implications.
Northamptonshire Police
Northamptonshire Police
Northampton — recommendation 4.2.3.4
Greater consideration should be given to the placement of officers/staff on restricted or ‘light duties’ taking account of their circumstances, the number allocated to a department and the additional stresses that can be caused to line managers.
Northamptonshire Police
Northamptonshire Police
Croydon — recommendation 29
Identifying and responding to domestic violence and the safeguarding of children and adults, is discussed with General Practitioners (from the GP practices concerned specifically in this review) during appraisal and revalidation.
NHS England
NHS England
East Sussex — recommendation 7
That the report is shared with the Ministry of Justice in order that: • the implications of shortages of probation officers on professional standards are noted • consideration is given, within the restructure of the probation services, to the professional registration of probation officers to ensure that individual standards of …
Ministry of Justice
Ministry of Justice
Basildon — recommendation 11.7.1
That Force Missing Persons Procedure should be reviewed to reflect the requirement to consider the use of specialist staff, including Missing Person Liaison Officers (MPLOs) and Children and Young People Officers (CYPOs), to conduct vulnerability interviews with frequent missing children. Additional emphasis should be placed on the need to conduct …
Essex Police
Essex Police
CJINI inspection reports(2)
DSA service inquiries(2)
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood
Service Inquiry into the death of an Acting Petty Officer whilst attending the Senior Rates Leadership Course at HMS Collingwood on 16 November 2020
Maritime
Mar 2022
Service Inquiry into the fatal collapse of a service person while undertaking a run in Sennelager, Germany, on 16 January 2023
The Service Inquiry report into the fatal collapse of a service person while undertaking a run in Sennelager, Germany, on 16 January 2023.
Other
Jul 2024