Staff training and development
Lack of effective systems to ensure staff receive appropriate training, ongoing support, professional development, supervision, and appraisal.
Source spread
Where this theme appears
This theme appears across 30 independent accountability sources, so the source mix matters as much as the headline total.
669 inquiry recs
1032 PFD reports
969 committee recs
195 HSSIB recs
1310 CQC actions
69 HMICFRS recs
47 ICIBI recs
232 PPO recs
315 IOPC recs
53 NAO recs
2 PHSO recs
1 VC rec
671 IMB recs
115 IMB reports
59 Scottish FAIs
32 Article 2 learning points
70 detention investigation recs
3029 DHR recs
6 PHSO decisions
99 LGO/SPSO decisions
12 CJINI reports
23 DSA service inquiries
3 ISC reports
10 CQC enforcement actions
4 EHRC compliance actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(669)— showing 50 strongest matches
16 — Soil mechanics for managers and surveyors
Recommendation: Managers and surveyors should as soon as possible be made aware of the rudiments of soil mechanics and ground-water conditions. The statutory qualifications for managers and surveyors should be amended to include awareness of the rudiments of soil mechanics and …
Unknown
15 — Training for those managing tips
Recommendation: Men engaged in the daily management and control of tips should be trained for their responsibilities (Paragraph 295).
Unknown
71 — Rigorous risk assessments
Recommendation: Steps should be taken to ensure that all risk assessments are rigorous and that those initiating risk assessments are appropriately qualified and informed. Steps include giving attention to HSE Guidance Notes covering risk assessment, which should accordingly be kept under …
Unknown
52 — Training and briefing for train crews on emergencies
Recommendation: Train crews should be given improved training and briefing on emergency actions, including a practical evacuation (para 11.11).
Unknown
20 — Training for information controllers
Recommendation: Level and quality of training for information controllers should be reviewed (para 9.15).
Unknown
8 — Monitor driver transfers and numbers trained
Recommendation: Railtrack and ATOC should monitor the transfer of drivers between operators and the numbers of drivers trained by each TOC and consider whether there are any safety implications involved (paras 5.5, 16.5).
Unknown
7 — National qualification and accreditation system for drivers
Recommendation: Railtrack together with ATOC should establish a national qualification and accreditation system for drivers including centrally held records to be available to the current employer (paras 5.5, 16.5).
Unknown
5 — Testing of driver competence and knowledge of the Rules
Recommendation: Testing of driver competence and knowledge of Rules should be extended to cover application of the Rules to practical situations, including all abnormal driving situations permitted by the Rules (para 16.4).
Unknown
4 — Driver training in abnormal situations
Recommendation: Driver training should include driving in abnormal situations permitted by the Rules and specifically driving with AWS isolated to the extent so permitted, including the use of simulators (para 16.4).
Unknown
3 — Simulators for driver training
Recommendation: Simulators should be introduced for driver training and for the observance of driver behaviour (para 16.3).
Unknown
1 — Co-operate on research into driver behaviour
Recommendation: All parties in the rail industry should co-operate in the collection of evidence to support reliable research into human behaviour studies relating to driver performance. Railtrack should co-ordinate this work and TOCs incorporate the results into training programmes (paras 1.25, …
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24 — Separate domestic and nursing duties
Recommendation: Domestic duties should, so far as possible, be separated from nursing duties and a special programme started for recruiting and training domestic workers.
Unknown
20 — Nurse training in co-ordination with Sharoe Green
Recommendation: Training for student and pupil nurses and experience of trained staff should be arranged in co-ordination with Sharoe Green and the new Preston hospital facilities to give adequate variety in all types of patient care.
Unknown
28 — RIO training on accident priorities
Recommendation: Consideration should be given to enhancing the training for RIOs to include additional guidance on priorities in the event of accidents and incidents where infrastructure failures are a predominant factor.
Unknown
21 — Ten-foot width guidance
Recommendation: Consideration should be given to the need for guidance to be included in training material, or in the Rule Book GE/RT8000, that specifies the width of ten-foot that is required to enable a person to stand in safety between two …
Unknown
20 — Patrolman training on stretcher bars
Recommendation: Consideration should be given to enhancing the competence of CE patrolmen, by the provision of additional training, to enable them to recognise and report emerging problems such as loose nuts and off-centre threads on adjustable stretcher bars, during basic visual …
Unknown
2 — Stretcher bar training programme
Recommendation: A training programme based on the guidance contained in Network Rail Company Code of Practice RT/E/C/10179, The Set Up and Maintenance of Adjustable Stretcher Bars - A Good Practice Guide should be developed. All signal installation and maintenance staff, their …
Unknown
62 — Training in informed consent
Recommendation: The Department of Health, the Royal Colleges and medical schools shall provide training for all those involved in obtaining fully informed consent.
Unknown
57 — Instruct doctors on Human Tissue Act
Recommendation: The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Human Tissue Act 1961, on the basis of our analysis, and the need for strict …
Unknown
49 — Training for Coroner’s Officers
Recommendation: The Home Office and the Coroners’ Society shall ensure all necessary training of Coroner’s Officers and ancillary staff.
Unknown
48 — Medical education for Coroners
Recommendation: The Home Office and the Coroners’ Society shall ensure all necessary medical education for Coroners.
Unknown
47 — Coroners’ Society instructions
Recommendation: The Coroners’ Society shall instruct Coroners that: – in the proper exercise of their judicial discretion, the decision to order a post mortem examination is not to be delegated to Coroner’s Officers and Deputy Coroners must be available at all …
Unknown
41 — Instruct doctors on Coroner’s Act
Recommendation: The Department of Health, the Royal Colleges and medical schools shall instruct members of the medical profession in the precise terms and provisions of the Coroner’s Act 1988 and in particular the circumstances in which it is obligatory to report …
Unknown
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
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
7 — Make trained staff available
Recommendation: The Chief Executive and Trust Board shall make available suitably trained staff for implementing the Serious Incident Procedure.
Unknown
186 — Police training in child care work
Recommendation: More extensive police training in work relating to matters of child care should be provided particularly in the work of interviewing children (19.22).
Unknown
184 — SWSG to promote training
Recommendation: SWSG should be given every encouragement to initiate and promote further and fuller facilities for training including joint training between agencies, to recognise the resource implications and to secure a level of training which will produce standards of practice to …
Unknown
183 — Specialist courses in social work
Recommendation: Every encouragement and support should be given to the creation and development of specialist courses in social work in Scotland with the involvement of practitioners from all agencies (19.18-19).
Unknown
182 — Training for others involved in child protection
Recommendation: Consideration should be given to the provision of training to all those outside the social work profession and the police who in one context or another may have an involvement in child protection work (19.17).
Unknown
178 — Extend management skills training
Recommendation: Training in management skills should be extended (19.13).
Unknown
177 — Post-qualifying training in interviewing
Recommendation: Planning should be started for developing more extensive post qualifying training to cover the complex subject of interviewing children in cases of suspected sexual abuse (19.10-12).
Unknown
176 — Interviewing children in qualifying training
Recommendation: Basic qualifying training for social workers when extended should include substantial tuition on interviewing children (19.10-12).
Unknown
175 — Resources for training needs
Recommendation: Local and central government should consider as a matter of priority the problems of resource and facilities involved in meeting that need (19.10).
Unknown
174 — ADSW to consider post-qualifying training
Recommendation: The need to increase facilities for post-qualifying training should be considered by ADSW (19.10).
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
171 — More social work training facilities
Recommendation: An increase in the facilities for training in social work is required and in particular for specialist training over the whole area of child care (19.7).
Unknown
170 — Child protection as specialist area
Recommendation: The whole area of work in child protection requires to be seen as a specialist area to be undertaken by practitioners with specialist skills and knowledge with adequate training and support (19.5-6).
Unknown
135 — Matters to consider before interviewing
Recommendation: Before embarking on an investigative interview interviewers should consider the matters of denial and retraction by a child, the interviewer’s knowledge of information relating to allegations, the interviewer’s own agenda, the use of leading questions and the introduction of personal …
Unknown
129 — Manager to know interviewer's support
Recommendation: An interviewer’s manager should have a clear understanding of all the people from whom the interviewer is receiving support (17.71).
Unknown
128 — Planned supervision of joint interviews
Recommendation: Where interviews are being undertaken jointly, supervision should be planned on an occasional but regular joint basis (17.70).
Unknown
127 — Supervision in complex interviews
Recommendation: Where interviews involve complex or multiple sexual abuse allegations there must be provided individual personal supervision, management supervision and detailed interview supervision (17.69).
Unknown
113 — Training in interviewing and recording
Recommendation: The importance of full training in the art of interviewing and the techniques of recording should be fully recognised (17.52).
Unknown
108 — Recognise complexity of interviewing children
Recommendation: There should be a greater recognition by agencies, training colleges, Central Government Departments and the public of the complexity of the task of interviewing children where allegations of sexual abuse arise (17.47).
Unknown
49 — Further training of JPs
Recommendation: Encouragement should be given to further training of JPs (16.21).
Unknown
39 — Training to consider child's self-protection
Recommendation: In all training in matters of child abuse account should be taken of the opportunity which a child has to take steps for his or her own protection (16.8).
Unknown
16 — Awareness for school administrative bodies
Recommendation: The administrative bodies of all schools should be helped to develop an awareness of the problems involved in child sexual abuse and the roles of the various agencies engaged in dealing with it (15.36).
Unknown
15 — Schools to link with Social Work Departments
Recommendation: The discovery of sexual abuse is not the monopoly of any agency. In particular, schools should establish close links with their local Social Work Departments. Teachers should be designated to be trained in the recognition of child sexual abuse and …
Unknown
14 — Joint training and joint guidelines
Recommendation: To assist in practical co-operation both agencies should engage in joint training and should prepare joint guidelines (15.33).
Unknown
Prevention of Future Deaths reports(1032)— showing 50 strongest matches
Alan Smith
Concerns: The coroner noted a co-worker had not received specific training for working at height. Generic risk assessment forms and method statements were available but not routinely used by employees.
Overdue
Dorothy Townley
Concerns: Insufficient direct communication between District Nurses and the GP, especially regarding patient condition, wound care, and urgent blood tests. The District Nursing Team also lacked knowledge and training in burns treatment, and their wound assessment chart was inadequate.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated it influences general practitioner training through its established GP Curriculum, which includes guidelines for best practice. • The College noted that its … (AI summary)
Responded
May Gibson
Concerns: The coroner noted failures in obtaining and utilising community care assessments, developing an adequate care plan for Mrs Gibson, and conducting proper risk assessments and reduction plans. Concerns were also raised regarding a lack of cohesive management and insufficient staff training and supervision within the care home.
Overdue
Labhuden Amarshi Vaghadia
Concerns: The coroner raised concerns about a community nurse administering anticoagulant medication without seeking medical advice despite previous bleeding, and failing to share this information with other professionals. The report also identified a lack of the nurse's professional insight and training.
Response (Leicestershire Partnership NHS): • The Trust conducted a review of Mrs Vaghadia's death and considered current community nurse practices for medication administration. • The Trust stated it would re-inform all healthcare professionals about … (AI summary)
Responded
Alfie-Scott Harris, Mohammed Mohinudeen and Caitlyn Bennet
Concerns: The coroner noted that Neonatal Unit (NNU) staff might underestimate the risk of cardiac tamponade as a complication of TPN feeding. Concerns were also raised that NNUs may not be sharing best practices effectively to limit this complication across different units.
Overdue
Michael Sweeney
Concerns: The coroner noted that the police use of 'excited delirium' is not widely understood by health services, potentially hindering proper diagnosis of medical emergencies. It was recommended that police training, control staff, and ambulance protocols be amended to use 'extreme agitation' to describe such conditions, ensuring appropriate prioritisation.
Response (Metropolitan Police Service): • The Metropolitan Police Service (MPS) and London Ambulance Service (LAS) have adopted 'Acute Behavioural Disorder' (ABD) as the common terminology for the constellation of symptoms, which is embedded in … (AI summary)
Response (London Ambulance Service): • The London Ambulance Service (LAS) stated it did not agree with the recommendation to amend its protocols and training to recognise 'extreme agitation' as a medical emergency, indicating it … (AI summary)
Responded
Jared William McDowall
Concerns: The coroner noted concerns with the transitional care cut-off weight guideline, suggesting it needed to differentiate by gestation and sex, with graphical risk presentation. There was also a need for improved joint working and staff education on hypoglycaemia and recognising unwell babies.
Response (University Hospital Bristol): • The Trust has developed a composite action plan. • Many actions described within the plan are currently underway. • The plan's implementation will be monitored through the Trust's governance … (AI summary)
Responded
Douglas Grey
Concerns: The coroner noted a lack of clear written procedure for notifying district nurses about equipment delivery, installation, and performance review. Additionally, carers did not recognise a faulty mattress or follow the home's policy for reporting equipment faults.
Overdue
Isabella Hope Hill
Concerns: The Trust's guidelines for umbilical venous catheter (UVC) insertion, specifically requiring an X-ray to confirm placement, were not followed. The coroner raises concerns about the absence of national UVC guidelines and the need for review and training.
Response (Liverpool Womens NHS): • The neonatal guideline for umbilical venous catheters was revised to include urgent assessment of catheter tip position for sudden deterioration and re-launched with new junior medical trainees. • Learning … (AI summary)
Responded
Annie Jones
Concerns: The coroner noted an inadequate mobility assessment for Mrs Jones, leading to her unsafe placement in a stand aid while non-weight-bearing. Concerns also included insufficient staff awareness of her limitations and safe equipment operation.
Responded
Anthony Hughes
Concerns: The coroner noted that police officers were unaware of excited delirium at the time of the incident and raised concerns about whether awareness training on this condition is now standard across all police forces in England and Wales.
Overdue
Elsie May Treece
Concerns: The coroner noted an alleged incident where a patient fell was not recorded, raising concerns that staff may not be adequately reporting all inappropriate incidents, even when major harm is not immediately apparent.
Response (Burton Hospitals NHS): • The Trust stated that staff receive training on incident reporting, including procedures for using paper-based forms during system downtime. • The Trust confirmed that additional training and support for … (AI summary)
Responded
William Andrews
Concerns: The coroner noted issues with medical equipment design, specifically syringe caps not being brightly coloured or visually distinct, and a lack of awareness among surgical teams that certain syringes now come with caps. Concerns also included the absence of a standard procedure for counting or checking these caps after operations.
Response (Department of Health): • The manufacturer, Rocialle, will now supply the syringe without the cap. • Rocialle has issued a safety notice to all UK customers. • Rocialle has agreed to make syringes … (AI summary)
Overdue
Damion Anthony Andre Martin
Concerns: Concerns were raised regarding the prison's initial risk assessment missing a known suicidal risk factor, the lack of refresher training in basic life support for officers, and a restricted cell observation window. An officer also reportedly did not visit the cell during a roll check.
Overdue
Kenneth Smalley
Concerns: The coroner noted concerns regarding an operating table moving uncontrollably due to issues with its handset, including possible fluid ingress and a non-functional emergency stop button. There was also a lack of hospital review for similar equipment and insufficient pre-operative checks for handset integrity.
Response (Wrightington Wigan and Leigh NHS): • The Trust developed specific checklists for each type of operating table and conducted thorough safety checks using qualified technicians. • A Standard Operating Procedure for theatre preparation, including daily … (AI summary)
Overdue
Anthony Brian Flynn
Concerns: The coroner identified insufficient training for prison officers on escorting prisoners during hospital visits and a lack of awareness among clinicians about their power to request restraint removal. This was highlighted by a sick prisoner being restrained during examination and a subsequent uninvestigated clinician complaint.
Response (Sodexo): • Sodexo stated it had reviewed training for prison officers regarding hospital escorts and procedures for making clinicians aware of their powers. • Sodexo confirmed it had prepared an escort/bedwatch … (AI summary)
Overdue
Keith Samuel Peters
Concerns: The coroner raised concerns about the allocation of Mr Peters' case to an officer on leave, insufficient prioritisation of the assessment, and the absence of a system to reallocate cases that could not be completed within the required 28-day period.
Response (Bolton Council): • The Council stated it had cascaded lessons learned from the case throughout the organisation. • The Council stated it had implemented developments and measures to improve systems, processes, and … (AI summary)
Responded
Derek Brierley
Concerns: The coroner identified gaps in Trust guidelines for competence and training for a suprapubic procedure. Concerns were also raised about the performing consultant's infrequent practice and the pre-procedure difficulty in locating necessary equipment.
Response (The Pennine Acute Hospitals NHS Trust): • The pathway for managing urinary retention has been re-drafted. • A training program for supra-pubic catheter insertion has been initiated. • The governance lead for urology will continue to … (AI summary)
Overdue
Linda Hudson
Concerns: Concerns were raised regarding the hospital's discharge process, specifically that the deceased was discharged with limited medication requiring daily collection due to self-harm risk, her family was not contacted, and the first follow-up nurse visit was scheduled too long after discharge.
Overdue
Martin McGlasson
Concerns: The coroner noted concerns regarding a widespread work method used in the industry and the need for risk assessments to be properly disseminated and explained to staff operating the process.
Response (DWF): • The company ceased the practice of storing staircases on their edges without restraint and installed a "TOAST RACK" support system. • It revised risk assessments and safe working procedures, … (AI summary)
Responded
Daniel Williams
Concerns: The coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.
Response: • All Inpatient staff received training packs and completed e-learning on 'Personalised Care Planning 2013 Record keeping and communication' in November. • The Trust developed and distributed guidance for checking … (AI summary)
Responded
Mary Waldron
Concerns: Nursing home staff failed to recognise an acutely unwell resident or act on low blood pressure, exacerbated by a lack of ongoing training. Managers also did not effectively investigate incidents and provided inaccurate reports to the Care Quality Commission.
Overdue
Craig White
Concerns: The coroner noted concerns regarding protocols for pre-Infliximab tuberculosis screening, the awareness of healthcare professionals about TB risk, and the need for ongoing patient education. Additionally, prompt treatment initiation for suspected tuberculous meningitis was highlighted.
Overdue
Lucy Goulding
Concerns: Concerns were raised regarding the lack of consultant supervision for on-call paediatric trainees admitting emergency patients and the absence of independent consultant assessment for paediatric admissions at Worthing Hospital. The report also noted a lack of national guidelines for assessing and investigating headaches in children.
Response (Womens Childrens Division): • The Trust strengthened paediatric consultant involvement in all three handovers between shifts. • A baton bleep was introduced for the Attending Physician, and discussion of paediatric patients not yet … (AI summary)
Overdue
Frederick Davidson
Concerns: The coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
Overdue
Joan Mary Jones
Concerns: The coroner noted that staff did not escalate Mrs Jones' care and failed to communicate all relevant information to healthcare professionals, which led to uninformed decisions and an inappropriate care package.
Response (The Manor): • A memo was issued to all unit leads to ensure family contact and the completion and sharing of communication sheets after visits from healthcare professionals. • The home's manager … (AI summary)
Responded
Tallulah Wilson
Concerns: Healthcare professionals lacked a good understanding of young people's evolving internet use and its impact on their wellbeing, highlighting a need for improved training and risk assessment refinement regarding digital lives.
Response (Department of Health): • The Policy Research Programme is funding a study by the University of Bristol, Samaritans, and Papyrus to explore internet use in relation to suicidal behaviour, with findings due in … (AI summary)
Responded
William Kent
Concerns: The coroner noted a lack of awareness and clarity regarding the safe use and potentially harmful side-effects of Haz-Tab granules for urine spillages, compounded by limited teaching during staff induction and updates.
Overdue
Samuel Boon
Concerns: The coroner noted insufficient and inaccurate information was given to participants and parents about the trip's risks and medical facilities. Concerns were also raised about inadequate risk assessments, lack of formal fitness assessments, and insufficient training for leaders on heatstroke and hyponatremia recognition and management.
Overdue
Adrian Cowan
Concerns: The trust's policy for responding to a patient collapse lacked clear guidance and did not require requesting a duty doctor. Nursing staff also did not act calmly or apply basic life support training effectively during the emergency response.
Response: • The Trust reviewed its resuscitation policy and committed to incorporating additional actions for deteriorating patients, expanding the NEWS Score, and clarifying the need to contact a duty doctor. • … (AI summary)
Overdue
Jack William Partington
Concerns: Concerns noted inadequate neonatal nursing handover, care planning, and isolated treatment decisions. Also, a lack of national policies for paralysing agents in neonates and insufficient ventilatory pressure monitoring post-intubation.
Response (Department of Health): • The Department of Health stated it would notify the British Association of Perinatal Medicine of the case. (AI summary)
Overdue
Edna Elsie Mary Eden
Concerns: The coroner identified delays in a patient receiving prescribed antibiotics and doctor review, alongside infrequent nursing observations and an incorrect EDOD score that prevented escalation. Communication gaps meant nurses struggled to contact doctors, and junior staff did not escalate significant backlogs or concerns.
Response (Heatherwood Wexham Park Hospital NHS Trust): • The Trust introduced Policy TPP 231 in August 2013, which includes requirements for verifying EDOD score calculations and strengthens the use of the SBAR communication tool. • A new … (AI summary)
Responded
Agostino Costa
Concerns: The coroner noted confusion among staff regarding patient-specific falls risks and classification. Inadequate post-fall management knowledge, insufficient dissemination of root cause analysis findings, and non-mandatory falls training were also identified.
Overdue
Abdullahi Sharif Abokar
Concerns: The coroner noted that some staff did not ask Mr Abokar about suicidal thoughts due to a mistaken belief, contrary to training. There were also significant issues with resuscitation procedures, including an unconnected ambubag and oxygen not being switched on.
Response (Camden & Islington NHS Trust): • The Trust commenced a Rapid Improvement Plan for Coral ward, which includes placing a new nurse manager and assessing staff competencies. • A revised Resuscitation Policy was approved, and … (AI summary)
Responded
Rachel Burke
Concerns: The coroner noted an unsafe trek itinerary with an ascent rate double recommended limits for altitude sickness. The trek leader underestimated a trekker's severe illness and hesitated to access medical care, possibly due to cost.
Response (The Family Adventure Company): • The company reviewed its Nepal high-altitude treks against Wilderness Medical Society guidelines and implemented adjustments to reduce altitude increases on some itineraries. • Additional information regarding higher daily altitude … (AI summary)
Overdue
Arthur Brockett-Deakins
Concerns: Concerns involved midwives' interpretation and escalation of abnormal CTG traces, particularly the inappropriate application of guidelines during a slow second stage of labour. The coroner also noted issues with CTG machines potentially displaying maternal heart rate as fetal heart rate due to an unknown multiplication factor, and the slow replacement of older models lacking differentiation.
Response (N.I.C.E): • NICE stated that its clinical guideline on Intrapartum Care (CG55) was currently being updated. • NICE reported that the update process included a re-examination of evidence on fetal assessment … (AI summary)
Response (Medicines Healthcare Products Regulatory Agency): • The Medicines Healthcare Products Regulatory Agency (MHRA) identified the cardiotocograph (CTG) model in use and contacted the manufacturer to determine if they had been notified of the incident or … (AI summary)
Response (NMC): • The NMC stated it would investigate information regarding a specific midwife as a new fitness to practice referral. • The NMC confirmed that policy and training on supervisory investigations … (AI summary)
Response (Department of Health): • The model of private midwifery provision described in the case was discontinued in July 2010 and no longer operates. (AI summary)
Responded
Lee Curran
Concerns: PPO recommendations for high cholesterol and NICE-compliant investigations for loss of consciousness were not fully implemented. The coroner also noted inaccurate medical record entries by prison staff and doctors' lack of awareness regarding NICE guidelines for transient loss of consciousness.
Overdue
Andre Matei
Concerns: The coroner identified a lack of national guidance on the role of interpreters during labour, especially when interpreters are required in a theatre setting.
Response: • The Secretary of State for Health stated that the matter would be brought to the attention of the National Institute for Clinical Excellence (NICE). • The Secretary of State … (AI summary)
Responded
Bertram Hamilton
Concerns: The coroner raised concerns about a nurse's apparent lack of knowledge regarding the contraindication of administering insulin to a person with very low blood sugar levels.
Overdue
Peter Norman Nott
Concerns: The coroner noted that the care home's procedures for post-fall examination were insufficient, as staff did not perform neurological observations. Concerns were also raised regarding inaccurate information provided to paramedics about the resident's consciousness.
Response (Elizabeth Finn Homes): • The organisation stated it would cascade updated procedures for neurological observations and head injury care to all clinical staff by April 1, 2014. • The organisation stated it would … (AI summary)
Responded
Anne-Marie Katherine Ellement
Concerns: The armed forces' code of practice for victims of crime does not specifically address victims of alleged serious sexual assault by another soldier. Additionally, staff implementing measures following a Suicide Vulnerability Risk Assessment received insufficient training and lacked regular follow-up training.
Overdue
Natasha Raghoo
Concerns: The coroner noted insufficient staff training in resuscitation, sporadic physical observations which ceased prematurely, and the lack of an electrocardiogram despite clinical need. Inconsistent staff handovers and unclear communication policies were also identified.
Response (Partnership in Care): • A programme of monthly emergency incident drills was implemented, and a company-wide training programme for Immediate Life Support, including defibrillator use, was delivered to qualified nurses and doctors. • … (AI summary)
Overdue
Andrew Hall
Concerns: Inadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.
Response (HM Prison and Probation Service): • The prison stated that ACCT reviews include recorded information from the mental health team, and mental health staff receive ACCT training, with further courses arranged for visiting psychiatrists. • … (AI summary)
Overdue
Jean James
Concerns: The coroner identified delays in initial documentation, an unreviewed omission of prophylactic Dalteparin, and ineffective communication of a pharmacy query. Concerns were also raised that existing systems and policies may not be robust enough to manage human factors.
Response (City Hospitals Sunderland): • The Trust reviewed its hospital information system (MEDITECH V6) and is implementing updates to automatically prompt VTE medication prescriptions and alerts. • The Trust introduced a new patient-focused format … (AI summary)
Responded
Jackson Chadd
Concerns: The coroner identified a lack of effective supervision for paediatricians, particularly during out-of-hours, and insufficient independent consultant assessment for paediatric admissions. Concerns also included the ineffective application of national guidelines for fever in children under one year and a failure to act on a parent's concerns.
Response (Frimley Park Hospital): • The Trust appointed a new Emergency Department Paediatric Consultant and established a consultant responsible for Paediatric A&E. • The Trust implemented a policy requiring junior doctors to notify a … (AI summary)
Response (Royal College of Paediatrics Child Health): • The Royal College of Paediatrics and Child Health (RCPCH) commenced a review of its 'Facing the Future' standards, specifically reconsidering the frequency of consultant review for admitted children. • … (AI summary)
Overdue
Oliver Hiscutt
Concerns: The coroner noted that paediatric child health training is not mandatory for GPs, with less than 25% of trainees undertaking placements, potentially leading to insufficient skills in assessing and responding to sick children.
Overdue
Frederick Hall
Concerns: The coroner noted a lack of skill and knowledge among staff regarding NG tube insertion and storage, alongside delayed responses to consultant instructions and patient deterioration. Deficiencies in communication between staff, poor record-keeping standards, and a need for more nursing/medical staff were also identified.
Overdue
Sari Keen
Concerns: Insufficient staffing levels led to staff feeling overwhelmed and unable to escalate care. Many staff were also unaware that an un-recordable blood pressure is a medical emergency requiring immediate resuscitation, suggesting a need to review crash team protocols.
Response (Luton Dunstable University Hospital): • The Trust confirmed processes are in place for adequate medical staffing and reinforced the importance of early escalation among staff. • A revised observation and escalation process is being … (AI summary)
Responded
Jennifer Tompkins
Concerns: The coroner noted potential training issues regarding the correct administration speed of IV medications and a lack of routine documentation when IV infusions are stopped early.
Overdue
Robert Perkins
Concerns: The coroner noted a lack of effort to fit a cervical collar despite neurosurgeon instructions, an absence of concern raised by most medical staff, and the unavailability of the prescribed collar in a specialist centre.
Response (North Bristol NHS Trust): • The Trust stated that the Emergency Department (ED) matron discussed communication failures with the nursing team and agreed that future communication should detail reasons for non-application of collars, interim … (AI summary)
Responded
Select committee recommendations(969)— showing 50 strongest matches
#85 —
Recommendation: In Chapter 3, we highlighted the pressures facing the construction skills workforce, the challenges of attracting and retaining talent, poor educational outcomes, and differences between expectations and the reality of working on a construction site. Mr Hopkins said that factory …
#72 —
Recommendation: The terms of reference for each new town delivery body must include a requirement to establish strong and effective working arrangements with employers and training providers. This should lead to the establishment of accredited training and apprenticeships tailored to the …
#71 —
Recommendation: In order to effectively capitalise on the opportunity that new towns can provide, Mr Hopkins urged delivery vehicles to ensure that there are sufficient training facilities available in the early stages of development. 116 Ms Egan argued that delivery bodies …
#69 —
Recommendation: Despite the many challenges related to construction skills, Simon Rawlinson, Deputy Chair of the Construction Industry Council, remained optimistic that the new towns programme could provide a “particularly interesting opportunity to apply the new skill sets that the industry needs”. …
#68 —
Recommendation: As part of the Government’s construction jobs plan, there should be a national review of non-degree construction training and apprenticeships. It should assess their effectiveness and relevance to modern day construction and to the needs of employers. It should also …
#64 —
Recommendation: We heard that construction training programmes are often highly fragmented themselves and rely on multiple different routes, which can be challenging to navigate for learners. 102 Ms Egan suggested that streamlining qualification routes could provide greater clarity. 103 We were …
#63 —
Recommendation: We heard that the fragmented nature of the construction sector presents a barrier to improving employer engagement with training opportunities, with employers and subcontractors moving frequently between sites and projects, making it difficult to provide continuity of supervision and mentoring. …
#61 —
Recommendation: While much of the historical discussion on construction skills focused on the quantity of workers, the Committee also heard that the quality of skills education is also a challenge. 94 Sam Egan, Group Director of Construction at the Bedford College …
#12 —
Recommendation: The terms of reference for each new town delivery body must include a requirement to establish strong and effective working arrangements with employers and training providers. This should lead to the establishment of accredited training and apprenticeships tailored to the …
#11 —
Recommendation: As part of the Government ’s construction jobs plan, there should be a national review of non-degree construction training and apprenticeships. It should assess their effectiveness and relevance to modern day construction and to the needs of employers. It should …
#11 —
Recommendation: As the BBC leans into the creator economy across the country, it should strategically develop its current estate with facilities that can harness the potential of new media and support the creator economy. It would be a statement of the …
#135 —
Recommendation: The Government and statutory bodies must meaningfully consult local planning authorities on new advice and policy which will have an impact on their decision making as competent authorities. This process must allow sufficient time for expertise in handling new policy …
Response attribution not verified
#126 —
Recommendation: This situation risks poorer outcomes for the environment owing to an inability of decision makers to apply environmental regulations and provide advice. 167 Natural England suggested this lack of the necessary skills had contributed to local planning authorities making increased …
Response attribution not verified
#109 —
Recommendation: Agencies and arm’s-length bodies have experience delivering policy ‘on the ground’ and in partnership with local communities and businesses. This is invaluable to the policy development process. Delivery expertise is necessary to ensure that policy is appropriate and is vital …
Response attribution not verified
#38 —
Recommendation: The Government and statutory bodies must meaningfully consult local planning authorities on new advice and policy which will have an impact on their decision making as competent authorities. This process must allow sufficient time for expertise in handling new policy …
Response attribution not verified
#31 —
Recommendation: Additional funding has been provided for statutory bodies. In 2024, a review should be undertaken of the availability and accessibility of expertise in Natural England and the Environment Agency to identify and address any remaining gaps in expertise.
Response attribution not verified
#7 —
Recommendation: If the Government thinks it is appropriate for competent authorities to be responsible for balancing economic, social and environmental priorities at permission stage, it must ensure that the necessary expertise is available within local authorities. Detailed guidance on the process …
Gov response: The Government agrees that highly skilled planners are fundamental to proactive local planning, securing high quality local design and placemaking, and running an efficient planning service for the communities they serve. They are invaluable in …
Accepted
#6 —
Recommendation: As a result of the requirement to mitigate harm at a project level, local planning authorities are attempting to balance decisions between unequally weighted principles. To overcome the statutory weight of environmental protection requires significant expertise and places great additional …
Response attribution not verified
#105 —
Recommendation: The Royal Marines deploy annually to Northern Norway for winter training and we were pleased to learn that the UK has increased the scale and frequency of cold-weather training and exercises in the High North. In March 2023, the UK …
Response attribution not verified
#104 —
Recommendation: Witnesses emphasised the highly specialised set of skills required to operate in the Arctic, which is one of the “worst battlespaces in the world to fight in”. 128 Lieutenant Commander Dr John Ash noted that: “You can take a competent …
Response attribution not verified
#134 —
Recommendation: We also heard that Youth Offending Services were able to communicate effectively with those they supervised. Justin Russell explained that speech and language therapists working in Youth Offending Services âare finding huge levels of communication need that have to be …
Response attribution not verified
#128 —
Recommendation: Initiatives for mentoring should be scaled up. Mentors can be people who have previously been on probation themselves or volunteers from the community. The Government should launch a national campaign to recruit mentors from the community. Charitable organisations should be …
Response attribution not verified
#119 —
Recommendation: When someone is sentenced to a community order, it is âvitalâ that they are assigned a peer mentor, we heard from Pavan Dhaliwal. She explained that someone who has previously been on probation can help an offender make the most …
Response attribution not verified
#118 —
Recommendation: We heard that mentors could encourage offenders engage with rehabilitation, whether they have been on probation themselves or are lay members of the public. Damian Hinds MP told us that âthere definitely is a roleâ for mentors. 230 He defined …
Response attribution not verified
#38 —
Recommendation: Recent recruitment and training waves should be sustained until vacancies are filled and the service effective. Efforts should be targeted at those areas where recent recruitment waves have been least successful. (Paragraph 215) An identity crisis (paragraphs 216 to 238
Response attribution not verified
#11 —
Recommendation: Pre-Sentence Reports produced by the Probation Service should include relevant information about the content, effectiveness , and availability of community sentences in the local area (see further conclusions and recommendations on Pre-Sentence Reports starting at paragraph 255 in Chapter 5). …
Response attribution not verified
#12 —
Recommendation: We reiterate the findings from our reports on the creative industries and digital exclusion: those most exposed to disruption from AI must be better supported to transition. The Department for Education and DSIT should work with industry to expand programmes …
Response attribution not verified
#27 —
Recommendation: Once the CPTPP task force comes to an end, the Government should aim to retain the expertise and experience to continue to engage UK businesses. It should make every effort to encourage the ongoing use of the agreement, and update …
Response attribution not verified
#46 —
Recommendation: The Government should work with industry to determine and set out an assessment and estimate of the numbers of skilled individuals that will be needed to deliver on its hydrogen targets, and across which professions, and work with industry to …
Response attribution not verified
#45 —
Recommendation: As with many other Net Zero ambitions, the availability of relevant skills, including all types of engineers and particularly those with experience of hydrogen, will be a barrier to scaling up technologies.
Response attribution not verified
#30 —
Recommendation: In the process of establishing the proposed national jobs and careers service, the Government should introduce further training for Work Coaches and DEAs to ensure they are fully able to understand the specific barriers young disabled people face, including in …
Response attribution not verified
#17 —
Recommendation: The Government should review training for careers advisers and leaders. This review should consider a) making in-depth SEN training a mandatory aspect of careers adviser qualifications, b) introducing a National Professional Qualification on careers education, information advice and guidance for …
Response attribution not verified
#16 —
Recommendation: Before June 2025, DfE should collect and publish data on the number of full-time equivalent careers advisers practicing in England and the number of advisers who have received specialist training relating to pupils with SEN .
Response attribution not verified
#3 —
Recommendation: The Government should make vocational profiling a standard part of careers information, advice and guidance for young disabled people in schools. The Government should have developed a clear plan, with a full timeline for implementing this, by September 2025, taking …
Response attribution not verified
#12 —
Recommendation: The Government should give the BBC an objective to engage with local news providers as strategic partners. This should involve expanding the Local Democracy Reporting Service and increasing the proportion of journalists allocated to small (including online-only) outlets. The BBC …
Response attribution not verified
#10 —
Recommendation: As part of its local media strategy the Government should seek partnership funding to support attraction and training schemes for local news, including apprenticeships .
Response attribution not verified
#9 —
Recommendation: The financial precarity of many jobs in journalism is not conducive to attracting a diverse workforce representative of the UK’s population. We welcome schemes from industry and the National Council for the Training of Journalists to attract and train under-represented …
Response attribution not verified
#164 —
Recommendation: The Government should invest in training and educating town centre managers, or other appropriate local authority staff, to ensure that every local authority has the required skills and expertise to provide tailored support to its own high streets. This could …
Response attribution not verified
#162 —
Recommendation: We note the Minister’s optimism that empowering local authorities will make them a desirable place to work and therefore address the capacity and skills gaps within such organisations. However, this is a long-term, indirect and unguaranteed solution to an immediate …
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
#43 —
Recommendation: The Government should invest in training and educating town centre managers , or other appropriate local authority staff, to ensure that every local authority has the required skills and expertise to provide tailored support to its own high streets. This …
Response attribution not verified
#42 —
Recommendation: Each local authority should have an active town centre manager to support the development of their high streets and town centres. Town centre managers across the country should share experiences and best practice to benefit from cohort-based learning.
Response attribution not verified
#41 —
Recommendation: We note the Minister’s optimism that empowering local authorities will make them a desirable place to work and therefore address the capacity and skills gaps within such organisations. However, this is a long-term, indirect and unguaranteed solution to an immediate …
Response attribution not verified
#31 —
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
#37 —
Recommendation: The Government should take steps to expand and improve awareness of the Trainee Scheme. Alongside this, the Government should consider how to subsidise or fund further professional development opportunities for interpreters in public services.
Response attribution not verified
#36 —
Recommendation: We welcome efforts to improve training and funding to those seeking level 6 qualifications through the Trainee Scheme managed by The Language Shop. However, there remains significant issues in the training and development opportunities for interpreters working in the courts.
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
#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
#113 —
Recommendation: A concern that was raised repeatedly in the evidence that we received related to the quality of supervision, which witnesses connected to the capabilities and experience of supervisory staff. The quality of supervision is central to the predictability of the …
Response attribution not verified
#24 —
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
HSSIB safety recommendations(195)— showing 50 strongest matches
Electronic patient record systems – electronic referrals for ongoing care
Organisations involved in the design and provision of healthcare education can improve patient safety by addressing gaps in knowledge and skill across the multidisciplinary workforce for the undertaking of asynchronous clinical consultation tasks, such as those undertaken through advice and …
Safety Observation
Timely detection and treatment of cauda equina syndrome
The British Orthopaedic Association has started to develop a Standard for Trauma and Orthopaedics (BOAST) to support the diagnosis and management of cauda equina syndrome in the non-specialist setting
Safety Action
Timely detection and treatment of cauda equina syndrome
It may be beneficial for hospital trusts without 24 hours a day, 7 days a week MRI provision and the potential to see patients with suspected cauda equina syndrome to consider expanding the skills of their radiographers to allow out-of-hours …
Safety Observation
Mental health: attempted suicide while under the care of community services
Organisational support for protected time, resources and assistance for staff to mitigate and respond to the distress and demands they experience in their role.
Area of Improvement
Mental health: attempted suicide while under the care of community services
Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
Area of Improvement
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
Do you have a dedicated and accountable professional lead for ensuring that local inductions are carried out?
Learning Prompt
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you ensure that inductions are carried out and that the time needed to complete local inductions is factored into the workload of staff?
Learning Prompt
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
Temporary staff – involvement in patient safety investigations
If an incident takes place, how do you ensure that temporary staff are able to record it?
Learning Prompt
Temporary staff – involvement in patient safety investigations
How do you ensure that temporary staff are aware of how to record patient safety incidents?
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Develop training in after action review and thematic analysis which includes a practical component where learners have an opportunity to apply the approach, to help ensure these learning responses are effective.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Increase access to education and training, focused on the application of system-based tools, and taught by people with demonstrable expertise, to help staff to carry out system-based investigations.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Support networks for knowledge sharing and collaboration for investigation staff to help foster learning about investigation practice.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide access to additional professional expertise and practical support to help investigators and learning response leads to apply system-based tools and guidance.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Provide guidance on the practical steps to take to decide on the most appropriate learning response to an incident, to help organisations adopt a robust, standard approach to their decision making.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Develop an accreditation process to assure the quality of PSIRF training.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Support PSIRF education and training to focus on the practical application of PSIRF tools, taught by people with demonstrable expertise in applying a system-based approach and tools in investigations.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Publish examples of patient safety incident investigations which include the PSIRF system-based tools and guides used to help investigators understand their application. Examples may be particularly beneficial in sectors that may have struggled with, or be new to, implementing PSIRF.
Learning Prompt
Investigating under the Patient Safety Incident Response Framework (PSIRF): sharing HSSIB learning for future development
Review and refresh the PSIRF learning response toolkit, to include the use of multimedia guides, to help make the tools and guides easier for investigators to use.
Learning Prompt
Insulin: supporting safe administration in inpatient settings
Organisations and individuals involved in the provision of clinical undergraduate and pre-registration education, and trust preceptorship/ induction programmes, can improve patient safety by using the findings of this report to prioritise diabetes care and insulin management education and training as …
Safety Observation
Healthcare provision in prisons: emergency care response — HSSIB
HSSIB recommends that HM Prison and Probation Service enhances the existing training delivered to prison officers, to increase their ability to identify medical emergencies that require 999 calls to be made by prisons, thereby reducing the number of calls and …
Safety Recommendation
Insulin: supporting safe self-administration for patients in the community with a disability
Does your organisation provide practical training and guidance to support staff to consider the mental capacity of patients to make decisions around their insulin when there are concerns capacity may be compromised?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
How does your organisation ensure that staff supporting the development of a person’s competency have the required knowledge and skills to provide that training and education in relation to diabetes and insulin?
Learning Prompt
Insulin: supporting safe self-administration for patients in the community with a disability
National bodies can improve patient safety by providing clarity on expectations around 1) how staff recognise that a patient’s mental capacity may be compromised in relation to decisions about their self-management of insulin, and 2) the undertaking of a mental …
Safety Observation
Insulin: supporting safe self-administration for patients in the community with a mental health problem
Organisations involved in the provision of undergraduate and pre-registration education and preceptorship/induction programmes can improve patient safety by ensuring that staff have knowledge of diabetes, an understanding of how and why insulin is a vital treatment for many people with …
Safety Observation
Medication related harm
HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including …
Safety Recommendation
Electronic prescribing and medicines administration: procurement and safety learning in acute hospitals
HSSIB recommends that NHS England/Department of Health and Social Care provides additional support to acute hospital trusts, in relation to: supporting healthcare providers to access digital clinical safety knowledge, capacity and capability integrating digital clinical safety and patient safety, including …
Safety Recommendation
Medication not given: discharge from an acute hospital to the community
How does your organisation enable staff to understand that a patient referral has been received, actioned, and completed?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
Does your organisation support staff to make timely and effective referrals to district nursing services to support insulin administration?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to identify and be able to refer to local diabetes specialist services when patients are discharged home?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to ensure that medications for an individual patient that are no longer needed are disposed of safely?
Learning Prompt
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to gain an understanding of the care patients with diabetes need?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation train staff to use local ePMA systems and record when patients require time critical medications?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you engage staff to understand the different requirements for electronic systems that may exist across the care pathway?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you enable staff to understand the context in which the care pathway may work in different organisations?
Learning Prompt
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Staff knowledge and insight into how community mental health services can support service users who may require prescription medication and who use drugs and/or alcohol.
Area of Improvement
Undetected button/coin cell battery ingestion in children
It is recommended that the College of Paramedics develops supervision guidance for paramedics, applicable to all relevant practice settings.
Safety Recommendation
Undetected button/coin cell battery ingestion in children
It is recommended that the Association of Ambulance Chief Executives agrees guidance that can inform its members on the competency and authority for staff to convey, refer and discharge children under five years who are subject to 999 calls.
Safety Recommendation
Wrong patient details on blood sample
Trusts can ensure that local policies and training on blood sampling account for the challenges posed by different working environments.
Learning Prompt
Electronic prescribing and medicines administration systems and safe discharge
During the implementation of any new digital system, benefits may be realised by redesigning work practices to ensure the new system is fully embedded, with staff training/engagement to support this.
Safety Observation
Electronic prescribing and medicines administration systems and safe discharge
There may be benefit for healthcare professionals to receive training in handover communications which should include integrating clinical information with full medicines information, and to share this information with patients and carers in writing and verbally.
Safety Observation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that PrescQIPP CIC supports its subscribers to identify the potential risk of prescribing propranolol to patients in at-risk groups.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the Royal Pharmaceutical Society supports its members in identifying the potential risk of prescribing propranolol to patients in at-risk groups.
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
It is recommended that the Royal College of General Practitioners supports its members in identifying the potential risk of prescribing propranolol to patients in at-risk groups
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that as part of the work to support the NHS Long Term Plan, NHS England and NHS Improvement should develop a role and competency framework for learning disability liaison nurses, to ensure that people with learning disabilities …
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that the Association of Anaesthetists reviews the dissemination and implementation of its ‘Quick reference handbook’ on managing adverse events during anaesthesia.
Safety Recommendation
Unplanned delayed removal of ureteric stents
It is recommended that the British Association of Urological Surgeons provides guidance for staff working within the stone care pathway to promote consistent advice to patients as part of discharge planning.
Safety Recommendation
Procurement, usability and adoption of ‘smart’ infusion pumps
There is a need to develop and evaluate ways of training clinicians and pharmacists on the use of safety-critical devices within a hospital to ensure that all staff that may operate the devices are suitably trained. Consideration should be given …
Safety Observation
Procurement, usability and adoption of ‘smart’ infusion pumps
Organisations involved in the development and deployment of smart pumps must ensure that their personnel are knowledgeable in clinical risk management. NHS Digital provides a programme of training to support this.
Safety Observation
Placement of nasogastric tubes
The Trust where the reference event happened implemented and recorded training and competency assessments for all nursing staff prior to allowing them to insert and confirm placement of nasogastric tubes.
Safety Action
NCEPOD recommendations(39)
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
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
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
Endometriosis
Wording not shown. See the report on NCEPOD's website.
Endometriosis
End of Life Care
Wording not shown. See the report on NCEPOD's website.
End of Life Care
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Emergency procedures in children and young people
Wording not shown. See the report on NCEPOD's website.
Emergency procedures in children and young people
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
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
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
CQC inspection actions(1310)— showing 50 strongest matches
Wexham Park Hospital
The trust must ensure that all staff complete the required mandatory training.
Must Do
Wythenshawe Hospital
The service must ensure staff are up to date with maternity mandatory training modules and that staff complete regular skills and drill training. Regulation 12(1)(2)(c)
Must Do
Worthing Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
Worthing Hospital
The trust must ensure that staff complete mandatory training in line with their role and that oversight of targets is effectively monitored.
Must Do
Worthing Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
Worcestershire Royal Hospital
The trust should ensure the programme of staff training for resuscitation and basic life support is continued.
Should Do
William Harvey Hospital
The trust should consider systems and processes which support managers own oversight of training completion rates and renewal dates held centrally by the trust governance team.
Should Do
William Harvey Hospital
The trust should ensure medical staff appraisal rates are improved.
Should Do
William Harvey Hospital
The trust should ensure staff are given regular appraisals. 18(1)(2)(a): Staffing.
Should Do
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 should ensure staff are given regular appraisals. 18(1)(2)(a): Staffing.
Should Do
William Harvey Hospital
The trust should ensure staff are given regular appraisals. 18(1)(2)(a): Staffing.
Should Do
William Harvey Hospital
The trust must ensure safeguarding training rates for medical staff are improved to the trust target.
Must Do
William Harvey Hospital
The trust must ensure staff training compliance rates for mandatory training are in line with the trust target.
Must Do
William Harvey Hospital
The trust must ensure staff at all levels complete the necessary training to enable them to carry out the duties they are employed to perform.
Must Do
William Harvey Hospital
The trust must ensure medical and nursing staff are up to date with mandatory training in key skills. This includes safeguarding adults and children training to the appropriate level.
Must 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
William Harvey Hospital
The trust must ensure medical staff are up to date with mandatory training in key skills. This includes safeguarding adults and children training to the appropriate level.
Must Do
William Harvey Hospital
The trust must ensure staff training compliance rates for Resuscitation training level 2 and level 3 are in line with trust targets.
Must Do
William Harvey Hospital
The trust must ensure all relevant staff are trained to the highest level of life support. This includes ensuring the Childrens Assessment Unit has a staff member on duty trained in Advanced Paediatric Life Support in line with the Royal …
Must Do
William Harvey Hospital
The trust must ensure all staff received mandatory training
Must Do
William Harvey Hospital
The trust must ensure medical and nursing staff are up to date with mandatory training in key skills. This includes safeguarding adults and children training to the appropriate level.
Must Do
West Suffolk Hospital
The trust should improve appraisal rates for midwifery staff.
Should Do
West Suffolk Hospital
The trust must ensure that medical and anaesthetic staff meet mandatory training compliance levels.
Must Do
Weston General Hospital
Take steps to improve training opportunities for middle grade doctors in the emergency department.
Should Do
Weston General Hospital
Continue to monitor and support senior medical staff in the emergency department to ensure they are equipped to provide the appropriate level of supervision to trainee doctors.
Must Do
Weston General Hospital
Ensure nursing staff are adequately supported with ongoing relevant training and supervision.
Must Do
Westmorland General Hospital
The service should consider protected time to allow for the completion of mandatory training.
Should Do
Westmorland General Hospital
The trust should consider what actions the service can take to improve safeguarding adults and safeguarding children level three training rates for doctors and nurses.
Should Do
Westmorland General Hospital
The trust should take appropriate actions to improve staff appraisal completion in line with trust compliance targets.
Should Do
Westmorland General Hospital
The trust should take appropriate actions to improve staff mandatory training, including safeguarding training in line with trust compliance targets.
Should Do
Westmorland General Hospital
The trust should ensure that all staff follow infection control principles, including the use of personal protective equipment (PPE) at all times and receive refresher training in this where deemed necessary.
Should Do
Westmorland General Hospital
The trust should ensure that the uptake of medicines management e-learning be prioritised to help improve medicines safety.
Should Do
Westmorland General Hospital
The service must ensure they deploy sufficient suitably competent and experienced staff and ensure all staff receive appropriate skills and drills training and professional development to enable them to maintain competency given the low numbers of deliveries.
Must Do
Westmorland General Hospital
The service must ensure medical staff complete all required safeguarding level 3 training.
Must Do
Westmorland General Hospital
The trust must implement an effective system to ensure that all clinical staff have the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Must Do
Westmorland General Hospital
The trust must take action to improve safeguarding adults and safeguarding children level three training rates for doctors and nurses.
Must Do
Westmorland General Hospital
The trust must ensure all relevant staff have completed Paediatric Advanced Life Support when supporting paediatric provision in the emergency department.
Must Do
Westmorland General Hospital
The trust must implement an effective system to ensure that all clinical staff have the knowledge, competence, skills and experience to care for and provide treatment to patients presenting with symptoms of stroke.
Must Do
West Cumberland Hospital
The trust must ensure that mandatory training including resuscitation, infection prevention and control and safeguarding meet the trust target for all staff.Regulation12(1)(2)(c).
Must Do
West Cumberland Hospital
The trust must ensure that all staff complete mandatory training to comply with targets for completion set by the trust.Regulation12(1)(2)(c).
Must Do
Watford General Hospital
The trust should ensure that all staff participate in the annual appraisal process.
Should Do
University Hospital of Hartlepool
The service should improve compliance with infection prevention and control training modules to meet the target.
Should Do
University Hospital of Hartlepool
The service should continue to improve compliance with appraisal rates in line with the trust target.
Should Do
University Hospital of Hartlepool
The service must ensure women who need additional care have access to appropriately trained specialist midwives.
Must Do
University College Hospital & Elizabeth Garrett Anderson Wing
The service should continue to ensure all staff complete mandatory training, including advance life support and safeguarding adults and children’s training in line with the trust’s own targets.
Should Do
The York Hospital
The service should ensure midwifery staff complete their mentorship training to provide them the skills to facilitate preceptorship programmes to new students and newly qualified midwifes.
Should Do
The York Hospital
The service should ensure service staff are trained in sufficient numbers to recognise or respond to the warning signs of sepsis in patients.
Should Do
The York Hospital
The service should ensure midwifery staff complete their mentorship training to provide them the skills to facilitate preceptorship programmes to new students and newly qualified midwifes.
Should Do
The York Hospital
The service should ensure all ED staff’s mandatory training modules are complete and compliance meets trust target, especially medical staff.
Should Do
HMICFRS recommendations(69)— showing 50 strongest matches
FRS 2018-19 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: Northamptonshire FRS needs to ensure that it has systems in place to effectively provide, record and monitor risk-critical training. Recommendation: By September 2019 the service must ensure that it provides, assesses and accurately records suitable operational training …
Recommendation
FRS 2018-19 CoC Recommendations: London Fire Brigade
Cause of concern: The Brigade has a significant backlog of training for staff in risk-critical skills such as incident command and emergency fire engine driving. Some staff haven’t had continuing training in these skills for many years. There is no …
Recommendation
FRS 2018-19 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Lincolnshire Fire and Rescue Service needs to assure itself that it has systems in place for the effective recording and monitoring of training. Recommendation: By 31 July 2019 the service must ensure that suitable operational training is …
Recommendation
FRS 2021-22 CoC Recommendations: Cumbria Fire and Rescue Service
Cause of concern: At the time of our inspection, the service couldn’t assure us that staff were maintaining risk-critical skills Recommendation: By 31 October 2022, the service must ensure it provides, assesses and accurately records suitable operational training, and that …
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, chief constables should review and update their learning and training provision relating to stalking to meet national policing curriculum outcomes, incorporate College of Policing e-learning, use external expertise, include local policies, and provide training to relevant …
Recommendation
FRS 2023-25 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since our last inspection to improve equality, diversity and inclusion. Recommendation: The service should improve equality, diversity and inclusion (EDI) by: • developing effective ways to show how it monitors and …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • engage with its staff to develop clear EDI objectives and …
Recommendation
FRS 2021-22 CoC Recommendations: North Yorkshire Fire and Rescue Service
Cause of concern: The service doesn't have in place adequate workforce planning processes. This means that areas such as safety-critical training, succession planning, absence and work-time management don't support its current and future integrated risk management plan. Recommendation: By September …
Recommendation
FRS 2021-22 CoC Recommendations: North Yorkshire Fire and Rescue Service
Cause of concern: The service doesn't have in place adequate workforce planning processes. This means that areas such as safety-critical training, succession planning, absence and work-time management don't support its current and future integrated risk management plan. Recommendation: By September …
Recommendation
FRS 2021-22 CoC Recommendations: North Yorkshire Fire and Rescue Service
Cause of concern: The service doesn't have in place adequate workforce planning processes. This means that areas such as safety-critical training, succession planning, absence and work-time management don't support its current and future integrated risk management plan. Recommendation: By September …
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 ensure that staff act in line with its values and are …
Recommendation
FRS 2021-22 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve how staff understand and display its expected values and behaviours. Recommendation: By 31 August 2022, the service should develop an action plan to ensure that staff …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service isn’t taking a proportionate approach to promoting equality, diversity and inclusion (EDI) in the workplace. Recommendation: By 31 August 2021, the service should make sure that senior leaders respond appropriately and quickly to EDI feedback …
Recommendation
FRS 2023-25 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since our last inspection to improve equality, diversity and inclusion. Recommendation: The service should improve equality, diversity and inclusion (EDI) by: • making improvements to the way it collects equality data …
Recommendation
FRS 2021-22 CoC Recommendations: Northamptonshire Fire and Rescue Service
Cause of concern: The service hasn’t made enough progress since the last inspection to improve EDI. Recommendation: By 31 August 2022, the service should develop an action plan to: • make improvements to the way it collects equality data to …
Recommendation
FRS 2018-19 CoC Recommendations: London Fire Brigade
Cause of concern: The Brigade has a significant backlog of training for staff in risk-critical skills such as incident command and emergency fire engine driving. Some staff haven’t had continuing training in these skills for many years. There is no …
Recommendation
FRS 2023-25 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: Since our last inspection, the service has made enough improvement to address two of our previous recommendations. But it still needs to improve equality, diversity and inclusion. The following recommendations remain in place. Recommendation: Within 28 days, …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t taken sufficient action since the last inspection to appropriately resource its protection function. Recommendation: By 30 September 2021, the service should review its administration of the protection function to make sure it can record …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t taken sufficient action since the last inspection to appropriately resource its protection function. Recommendation: By 30 September 2021, the service should make sure it has an effective quality assurance process in place so the …
Recommendation
FRS 2021-22 CoC Recommendations: Lincolnshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve its EDI. Recommendation: By 30 September 2021, the service should improve how it works with its staff and provides feedback in relation to EDI issues.
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 2018-19 CoC Recommendations: Hampshire and Isle of Wight Fire and Rescue …
Cause of concern: Hampshire Fire and Rescue Service doesn’t do enough to be an inclusive employer. We found signs of low morale in the workforce. People have little confidence that they will be treated fairly or that senior leaders have …
Recommendation
FRS 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 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: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS doesn’t have enough controls in place to monitor the competence of its staff. This is because it has suspended its centralised assessment of incident command and breathing apparatus training. Recommendation: The service should ensure …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
FRS 2018-19 CoC Recommendations: Greater Manchester Fire and Rescue Service
Cause of concern: Greater Manchester FRS has no strategy, visible leadership and limited training on equality, diversity and inclusion. This is affecting watch culture and undermining positives steps to attract new entrants from diverse backgrounds. Recommendation: By 31 December 2019, …
Recommendation
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • …
Recommendation
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • …
Recommendation
FRS 2023-25 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since our last inspection to embed its values and associated behaviours and promote a positive workplace culture. The service has done enough to complete the following recommendations from our 2021 inspection: • …
Recommendation
FRS 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 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 make sure …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to improve how …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to embed its values and associated behaviours and promote a positive workplace culture. Recommendation: By 28 February 2022, the service should develop an action plan to establish effective …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 …
Recommendation
FRS 2021-22 CoC Recommendations: Gloucestershire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to improve understanding and awareness of the importance of equality, diversity and inclusion (EDI) and remove barriers to embedding EDI in the service. Recommendation: By 28 February 2022 …
Recommendation
FRS 2018-19 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: The service has insufficient resources to meet its risk-based inspection programme. It is currently not meeting its targets. As a result, partially-skilled operational staff are carrying out high-risk visits, although the service acknowledges these are not audits. …
Recommendation
FRS 2021-22 CoC Recommendations: Essex County Fire and Rescue Service
Cause of concern: The service has insufficient resources to meet its risk-based inspection programme. It is currently not meeting its targets. As a result, partially skilled operational staff are carrying out high-risk visits, although the service acknowledges that these are …
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
A joint thematic inspection of the police and Crown Prosecution Service's response …
By September 2022 ensure regular clinical supervision available to all prosecutors dealing with rape/RASSO cases
Recommendation
How the police respond to victims of sexual abuse when the victim …
Update existing sexual abuse APP to include risk of honour-based abuse
Recommendation
How the police respond to victims of sexual abuse when the victim …
Update forces' sexual abuse policies to include the risk of honour-based abuse
Recommendation
The hidden victims: Report on Hestia's super-complaint on the police response to …
Ensure officers can identify victims, understand NRM, recognise s.45 defence, and know support available
Recommendation
The policing response to antisocial behaviour: PEEL spotlight report
ASB training and mandatory process for collecting, analysing and publishing data on antisocial behaviour
Recommendation
An inspection of the effectiveness of the police and law enforcement bodies' …
By 31 December 2024, ensure sufficient measures in place to identify group-based CSE and adopt national definition
Recommendation
FRS 2018-19 CoC Recommendations: West Sussex Fire and Rescue Service
Cause of concern: West Sussex FRS doesn't have a clear strategy for using its risk-based inspection programme to identify the highest risk premises. The database it uses to manage premises information is unreliable and not always accurate. The service can't …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should review its risk-based inspection programme to make sure …
Recommendation
FRS 2021-22 CoC Recommendations: Warwickshire Fire and Rescue Service
Cause of concern: The service hasn’t done enough since the last inspection to determine its highest risk premises to inform its risk-based inspection programme. Recommendation: By 31 August 2021, the service should put in place a clear plan with timescales …
Recommendation
ICIBI immigration recommendations(47)
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 1 Review the Stansted “staffing formula” and ensure overall numbers, including the “Seasonal Workforce (SWF)”, are sufficient to enable permanent staff to be released for skills training, and allow …
An inspection of Border Force operations at Stansted Airport
Recommendation 1 Review the Stansted “staffing formula” and ensure overall numbers, including the “Seasonal Workforce (SWF)”, are sufficient to enable permanent staff to be released for skills training, and allow …
An inspection of the use of deprivation of citizenship by the Status …
Training and Guidance - Review the resourcing and role specific training required by the training team to ensure they are equipped with the skills, knowledge, and resource to meet the …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 3 Provide appropriate training and support for newly-promoted Border Force Higher Officers (BFHO) to enable them to become fully-effective managers in the minimum time.
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 2 Support and encourage permanent staff to become “multi-functional officers”, ensuring that those who wish to do so are able to access places on all 3 “Core Skills” training …
An inspection of Border Force operations at Stansted Airport
Recommendation 3 Provide appropriate training and support for newly-promoted Border Force Higher Officers (BFHO) to enable them to become fully-effective managers in the minimum time.
An inspection of Border Force operations at Stansted Airport
Recommendation 2 Support and encourage permanent staff to become “multi-functional officers”, ensuring that those who wish to do so are able to access places on all 3 “Core Skills” training …
An inspection of Border Force insider threat (January – March 2023)
Make insider threat awareness training part of formal induction training for new recruits and mandatory training for existing staff.
An inspection of asylum casework (August 2020 – May 2021)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
An inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Review the role of team leaders and introduce professional supervision and support to ensure they are able to meet the challenges of managing operations to safeguard the safety and welfare …
An inspection of the Border Force intelligence functions at the Humber ports …
Review the training and accreditation provision for Border Force intelligence staff to:ensure training and accreditation pathways are agreed and in place for all intelligence rolesensure staff receive role-specific training on …
An inspection of asylum casework (June – October 2023)
To address workplace culture, create a mandatory regular ‘face behind the case’ style training course focused on asylum
An inspection of Border Force practice and procedures in relation to firearms …
Develop and implement a continuous professional development plan for all Make Safe Officers, ensuring that there is a mechanism in place to access technical support.
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to training: a) Ensure that wherever peers rather than specialist trainers are used to deliver initial training (as with IECA decision makers) they have received at least basic …
An inspection of General Maritime (October 2024 – February 2025)
Create and maintain a centralised record of what training every Border Force officer has completed and their training needs (including for refresher training), readily accessible to regions and commands, so …
Inspection report of Birmingham Airport, February 2013
Accepted - The Home Office recognises the benefits hosts can bring to assist the efficiency of queue management. The provision of hosts is the responsibility of port operators, and we …
Inspection report of Border Force operations at Stansted Airport, January 2014
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
A short inspection of Border Force queue management at Birmingham Airport based …
Accepted - The Home Office recognises the benefits hosts can bring to assist the efficiency of queue management. The provision of hosts is the responsibility of port operators, and we …
An inspection of illegal working enforcement (August – October 2023)
Implement a system to allow operational staff access at all times to up-to-date and succinct guidance.
A re-inspection of the use of hotels for housing unaccompanied asylum-seeking children …
Review the role of team leaders and introduce professional supervision and support to ensure they are able to meet the challenges of managing operations to safeguard the safety and welfare …
An inspection of Border Force practice and procedures in relation to firearms …
Conduct a firearms training needs analysis and review of existing national training provision to define the mandatory attendance requirements and to ensure that the quality and availability of training delivery …
An inspection of Border Force practice and procedures in relation to firearms …
Address the firearms risk of Border Force staff conducting searches under immigration or customs powers without completing the Firearms & Explosives Awareness and Recognition (FXAR) training course.
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to safeguarding, establish a dedicated, full-time safeguarding team within the IECA with the capacity and expertise to: a) Respond to all cases where a safeguarding risk (Levels One, …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to quality assurance: a) Ensure that the ratio of tech specs to DMs in the IECA is sufficient to prevent ‘second pair of eyes’ (SPOE) backlogs and slow …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to NRM referrals: a) By November 2024, evaluate the new (as of April 2024) training package for Immigration Prison Teams (IPTs) and Detention Engagement Teams (DETs) with reference …
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to recruitment and workforce planning: a) Review recent instances where the department has recruited at speed and in large numbers to resource new or expanding functions (including the …
An inspection of the Border Force operation to deter and detect clandestine …
Overhaul training provision for front-line Border Force officers at the juxtaposed ports to ensure that they are as far as possible multi-functional and can be deployed flexibly, in particular: a) …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to initial age assessments and decisions: With input from KIU’s ‘in-house’ social workers and the NAAB, set minimum quality standards for the KIU triage process at Western Jet …
An inspection of the Home Office’s use of age assessments (July 2024 …
In relation to initial age assessments and decisions: Before the end of 2025, conduct a formal evaluation of initial age decision training, meanwhile involving Kent Intake Unit’s ‘in-house’ social workers …
An inspection of General Maritime (October 2024 – February 2025)
Produce a short-term (1-2 years) succession plan for Border Force Maritime Command (BFMC), identifying the risks, mitigations and contingencies involved with filling key posts, and setting out the work required …
An inspection of asylum casework (August 2020 – May 2021)
To help improve retention, ensure there is clarity among DMs on opportunities for progression and, in consultation with DMs, conduct a review of InSight weekly targets
An inspection of asylum casework (June – October 2023)
To help improve retention, ensure there is clarity among DMs on opportunities for progression and, in consultation with DMs, conduct a review of InSight weekly targets
An inspection of the Immigration Enforcement Competent Authority (January – June 2024)
With respect to IECA decisions: a) Clarify the process(es) that DMs should follow where they consider that they have insufficient evidence to make a positive decision, including where this is …
An inspection of the Home Office’s management of fee waiver applications (August …
Overhaul how the quality and consistency of the work of fee waiver caseworkers (not solely decision outcomes) is managed, defining the roles and responsibilities of line managers, ‘technical specialists’, and …
An inspection of the Home Office’s management of fee waiver applications (August …
Create a more exacting ‘quality score marking’ system for use with fee waiver caseworkers that reinforces the importance of eliminating all errors, giving more weight than hitherto to correct spelling, …
An inspection of the Home Office’s management of fee waiver applications (August …
Formalise regular (at least quarterly) meetings of senior managers and caseworkers from the three fee waiver teams to share information and promote ‘best practice’ and consistency, and to flag and …
An inspection of Border Force operations at Stansted Airport
Recommendation 7 Ensure that all Border Force staff at Stansted, including the “Seasonal Workforce (SWF)”, understand the need for, and are allocated sufficient time to produce, an accurate and detailed …
An inspection of Border Force operations at Stansted Airport
Recommendation 6 Review the guidance to “Monitoring Officers” regarding their safeguarding responsibilities and produce workable advice on how they are to satisfy themselves that a child or young person, or …
An inspection of Border Force operations at south coast seaports
Accelerate the publication of guidance from the consultation on the use of Personal Protective Equipment (PPE). 4.10. Accepted. 4.11. Body armour is only one element of the control measures that …
An inspection of Border Force insider threat (January – March 2023)
Conduct role-based risk assessments in key areas and specialist roles.
An inspection of Border Force’s fast parcels operations (May–July 2023)
Set and assure performance expectations for all staff working in fast parcels.
An inspection of Border Force’s fast parcels operations (May–July 2023)
Review current methodologies for the search and transportation of suspected prohibited and restricted goods to:
An inspection of Border Force’s fast parcels operations (May–July 2023)
Designate a single national team to manage detection equipment who should:
An inspection of General Maritime (October 2024 – February 2025)
To support the Maritime Director in promoting a consistent Home Office-wide approach to general maritime, identify GM leads at regional/command and ports levels and establish a national network that links …
Inspection report of Border Force operations at Stansted Airport, January 2014
The Home Office response to the recommendations In relation to resourcing and training:
Inspection report on an interim re-inspection of family reunion, July 2017
In consultation with decision team managers (DTM), conduct a review of the DTM role and responsibilities.
An inspection of Border Force operations at Stansted Airport
The Home Office response to the recommendations In relation to resourcing and training:
PPO death in custody recommendations(232)— showing 50 strongest matches
SSCL
SSCL should provide refresher training to its switchboard staff to ensure that they know what to do when they receive calls raising concerns about a prisoner’s wellbeing.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies, in particular that staff efficiently communicate the nature of a medical emergency using the appropriate code.
The Governor and Head of Healthcare
identify what training is needed so there is clear understanding of the lawful authority of prison staff, and when the Mental Capacity Act should be used instead, or in parallel.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff receive training on the Mental Capacity Act and that staff know when and how to assess mental capacity.
The Head of Healthcare
The Head of Healthcare to assure herself that the healthcare staff who undertake the role of Nurse in Charge on H3 have the sufficient skills and competencies to recognise a clinically deteriorating patient.
The Head of Healthcare
The Head of Healthcare should review the systems and processes for training and supporting staff to complete escort risk assessments for patients requiring emergency hospital admission.
The Head of Healthcare (HMP Styal)
The Head of Healthcare should ensure that staff understand how and when to administer adrenaline in medical emergencies and that they have received the appropriate training to do so.
The Governor and Head of Healthcare (HMP Styal)
The Governor and Head of Healthcare should review how staff are trained on the use of medical emergency codes and satisfy themselves that all staff are aware of their responsibilities during medical emergencies.
The Governor and Head of Healthcare of HMP Wormwood Scrubs
The Governor and Head of Healthcare should introduce a robust quality assurance process to assure themselves that: all staff involved in the escort risk assessment process receive training on the Graham judgment and have a clear understanding of how it …
The Head of Healthcare at HMP Wandsworth
The Head of Healthcare should ensure that agency staff receive an appropriate induction when they start at Wandsworth so that they are clear about the expectations of healthcare staff at the prison.
The Director of HMP Peterborough
The Director should review the local training programme for control room staff to ensure that it is sufficiently rigorous, includes the full range of frequently occurring events and an understanding of the actions required by national instructions, and involves an …
The Governor of The Mount
The Governor of The Mount should ensure that all staff understand their responsibilities about calling emergency codes so that emergency responses are timely.
The Governor
The Governor should ensure that when staff draw a radio or receive one from another staff member, they check that the radio is functioning correctly and is set to the appropriate channel.
The Governor
The Governor should ensure that staff are aware of the signs of rigor mortis, and fully understand the circumstances in which they should not start, or continue, resuscitation, in line with Resuscitation Council Guidelines.
The Governor
The Governor should share a copy of this report with CM A and arrange for a senior manager to discuss the Ombudsman’s findings with him.
The Head of Healthcare
The Head of Healthcare should ensure that: • the welfare check sheet used for monitoring prisoners suspected to be under the influence of a substance includes timescales for review, escalation and transfer to hospital; and that • training is provided …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff know how to use TOXBASE and escalate cases of concern promptly.
The Head of Healthcare
The Head of Healthcare should ensure that prison staff in the FNC have written guidance on what symptoms they should watch for in detoxing prisoners and when they should seek medical help.
The Governor
The Governor should consider detoxification awareness training for all officers who work in the First Night Centre, to ensure safe and supportive management of prisoners withdrawing from drugs.
The Governor
The Governor should remind all staff of the appropriate emergency codes and how these should be used.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff contributing to the ACCT process have the necessary training.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that a copy of this report is shared with all staff named in this report and that a senior manager discusses the Ombudsman’s findings with them.
The Governor and Head of Healthcare
reception staff are appropriately trained.
The Governor
The Governor should ensure that staff are aware of their responsibilities during medical emergencies, including that they should call the appropriate medical emergency code immediately.
The Head of Healthcare
The Head of Healthcare should ensure that all staff receive training in two stage mental capacity assessments.
The Governor
The Governor should ensure that all staff are fully aware of and understand their responsibilities in a medical emergency, including the use of an emergency response code if a prisoner has breathing difficulties, or is unresponsive.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff are aware of the circumstances in which resuscitation is inappropriate.
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should commission an outreach service from the community diabetes team to ensure that nursing staff are adequately trained and know when to seek advice from secondary services.
Governors of prisons with MCBS units
Governors should ensure that: contingency plans are in place for a range of possible incidents in MCBS units; staff who may be called upon to act as Silver Commanders have received the appropriate training, including refresher training and have a …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff follow the protocols for clinical escalation as per NEWS2 and sepsis pathways.
The Head of Healthcare
The Head of Healthcare should ensure the local operating policy for managing omitted doses of medication is reviewed and includes more specific and clearer guidance to the Pharmacy Team on the management (including when to alert the GP) of in-possession …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff are compliant in the correct level of safeguarding training in accordance with their roles as set out in the Royal College of Nursing (RCN) Intercollegiate Document for ‘Adult Safeguarding: Roles and …
The Head of Healthcare
staff use appropriate clinical assessment and monitoring tools.
The Governor and Head of Healthcare
ensure that staff use appropriate interpretation services when discussing complex matters with prisoners with limited English language skills.
The Governor
The Governor should ensure that staff are offered appropriate support, including access to TRiM practitioners, following a death in custody or other traumatic event.
The Head of Healthcare
The Head of Healthcare should share a copy of this report with Senior Nurse A and Nurse B and discuss the Ombudsman’s findings with them.
The Governor of HMP Leyhill
The Governor should ensure that a senior manager debriefs all relevant staff immediately following a death in custody and that they receive appropriate support afterwards.
The Governor of HMP Leyhill
The Governor should ensure that all staff are aware of the location of defibrillators and that they understand how to access and use them during a medical emergency.
The Governor
The Governor should ensure that all prison staff are made aware of and understand their responsibilities during medical emergencies.
The Head of Healthcare
The Head of Healthcare should ensure that staff understand when they should make referrals under the suspected cancer pathway.
The Head of Healthcare
The Head of Healthcare should ensure that clinical staff receive training on when to make referrals under the two-week wait cancer pathway, in line with national guidance.
The Governor of HMP Holme House
The Governor should ensure that local systems and arrangements are in place for effective post-incident care for staff who are exposed to distressing or traumatic events during their duties.
The Head of Policy and Capability in the Security Directorate …
The Head of Policy and Capability in the Security Directorate of HMPPS should amend the Use of Force Policy Framework to include the particular references to sickle cell disease that were contained in PSO 1600 and ensure that national use …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should examine Reception practices and devise a plan to ensure that all relevant staff read and appropriately respond to information contained in Person Escort Records when processing prisoners.
The Head of Healthcare
The Head of Healthcare should check and ensure that all staff, including agency staff, have been trained to access the digital Person Escort Record.
The Barnet, Enfield and Haringey Mental Health Trust Service Manager
The Barnet, Enfield and Haringey Mental Health Trust Service Manager should ensure that the RMN and all H3 staff are invited and have the opportunity to engage in a reflective session utilising the Practice Plus Group reflective presentation already completed. …
Practice Plus Group and NHS England and Improvement
Practice Plus Group and NHS England and Improvement should undertake further enquiries to ensure that healthcare agencies which provide staff to prisons are appropriately trained, competent and are practising safely
The Head of Healthcare
The Head of Healthcare should ensure that all staff are aware of the normal range for clinical observations, the relevance of finding an abnormal physical observation and action to take when this is noted.
The Head of Healthcare
The Head of Healthcare must ensure that all healthcare staff are trained and competent in the use of the NEWS2 assessment.
The Director of HMP Fosse Way
The Director should review the prison’s local instructions on roll checks, unlocking and welfare checks to ensure that there are sufficient quality assurance processes in place to establish that: • staff are clear about the type of check required, when …
IOPC learning recommendations(315)— showing 50 strongest matches
Police response to an abandoned emergency call – Cleveland Police, March 2020
The IOPC recommends that Cleveland Police take steps to ensure all current and future officers and staff that work in the control room receive sufficient training, in order to perform their roles effectively. Refresher training should be provided as necessary, …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should review and ensure the adequacy of its current training and guidance on the requirement by police officers to report, challenge or take action against the conduct of colleagues. This should include the responsibilities …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should review and ensure its current training and guidance on bullying and harassment adequately covers when remarks that may be viewed by some as ‘friendly’ banter, can create an intimidating, hostile, degrading, humiliating or …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should review and ensure the adequacy of its current training and guidance on the appropriate use of social media, including duties under the Code of Ethics that extend to officer’s private lives. In particular, …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should build on the steps it has taken internally against bullying and harassment, by publicly committing to a position of zero-tolerance on bullying and harassment, which is embedded through messaging, guidance, training and on-going …
Investigation into response to a concern for welfare - Greater Manchester Police, …
The IOPC recommends that Greater Manchester Police takes steps to ensure that the staff within the Force Control Centre understand the importance of the escalation policy and the individual responsibilities laid out within the policy for escalating incidents when they …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police review training for Call Centre staff with regard to risk grading and that domestic violence incidents graded 1 or 2 receive a prompt response. This should be done by continuous dip sampling to check …
Recommendations - South Wales Police, July 2022
The IOPC recommends that South Wales Police provide training to custody and detention officers regarding the Prisoner Escort and Custody System (PECS) and the completion of digital Person Escort Record (d PER) forms. Any such training should highlight that: PECS …
Recommendations - Thames Valley Police, December 2024
The IOPC recommends that Thames Valley Police (TVP) ensure that its training and guidance on restraint and positional asphyxia clearly states the role and responsibilities of the safety officer. This includes when a safety officer should be used, the safety …
Recommendations - Thames Valley Police, December 2024
The IOPC recommends that Thames Valley Police (TVP) review its training material on handcuffing from prone (subject lying on their front) and the use of ground pin. The review should consider whether training is sufficiently clear regarding: - How a …
Recommendations - Thames Valley Police, May 2025
The IOPC recommends that Thames Valley Police (TVP) takes steps to ensure that frontline officers understand, and are confident in applying, guidance on method of entry. As part of this, the force should make clear the expectations on officers who …
Recommendation - Thames Valley Police, February 2026
The IOPC recommends that Thames Valley Police (TVP) take steps to satisfy themselves that complaint handlers and investigating officers outside the Professional Standards Department (PSD) are being properly supported in their role. In doing so, TVP should review what training, …
Recommendations - West Midlands Police, June 2021
The IOPC recommends that West Midlands Police create a detailed question set for call handlers responding to requests from external agencies to conduct welfare checks. The prompts should help call handlers to elicit key information to help inform decision making …
Recommendations - West Midlands Police, July 2023
The IOPC recommends that West Midlands Police (WMP) should review the first aid training of WMP officers, to consider whether a single day of training is sufficient to accommodate the necessary teaching for both personal safety and first aid, and …
Recommendation - Derbyshire Constabulary, April 2026
The IOPC recommends that Derbyshire Constabulary should review and update its operational guidance and officer training on responding to suicide-related incidents to ensure officers clearly understand the legal powers available to them to remove items that pose an immediate risk …
Recommendation - Metropolitan Police Service, February 2026
The IOPC recommends that the Metropolitan Police Service (MPS) review its training on officers’ participation in WhatsApp group chats and the requirement to report unacceptable behaviour and/or language through the appropriate channels. This review should consider whether training is sufficiently …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends the MPS should create a role profile for Directorate of Professional Standards (DPS) investigators and DPS IOPC Single Point of Contacts (SPoC), outlining the requirements of the role and the role holder’s key responsibilities. The MPS should …
Recommendations - Metropolitan Police Service, June 2020
The IOPC recommends that the MPS Should consider providing role specific training to all of its professional standards investigators. It is recommended that this training addresses the following requirements: - The legal obligation under s21 Police Reform Act 2002 of …
Complaints raised in relation to detention in custody – Essex Police, June …
The IOPC recommends that Essex Police take steps to ensure custody staff, in particular custody officers and healthcare professionals, understand when detained persons require an Appropriate Adult. This should include: Providing updated training on the legislation and national guidance regarding …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP consider using this incident as an anonymised case study to promote learningamong officers. This should include consideration of: 1. how officers responded to this incident; and 2. explore (drawing upon best practice) what alternative actions could …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP take steps to ensure that when a detainee is brought into custody: 1. the custody officer makes sure appropriate enquiries are undertaken to confirm whether the detainee has any medical conditions and, if so, whether the …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP take steps to ensure custody staff, in particular custody officers and healthcare professionals, understand when detained persons require an Appropriate Adult. This should include consideration of: 1. Issuing communications to custody officers reminding them when a …
An investigation into complaints made about the treatment of a man with …
The IOPC recommends SWP take steps to ensure police officers and custody staff are supported to identify and interact with people who have neurodiverse needs, including those with autism spectrum conditions. This should include consideration of the training and guidance …
Complaints raised by family after recovery of young teenager's body - South …
The IOPC recommends that South Wales Police takes steps to ensure all relevant officers and staff, included but not limited to: Gold, Silver, and Bronze Commanders and Force Incident Managers, receive training on the following policies and how they interact …
Recommendations - North Wales Police, January 2025
The IOPC recommends that North Wales Police review, and where necessary amend, their training, guidance and policies provided to police officers and staff about how to write a statement. This learning recommendation has arisen following an IOPC investigation review following …
Recommendations - Gloucestershire Constabulary, March 2025
The IOPC recommends that Gloucestershire Constabulary should review their training in relation to stalking to ensure that: - Training on stalking has been fully put in place. - All Neighbourhood Policing Team (NPT) officers receive training on the identification of …
Recommendations - Gloucestershire Constabulary, March 2025
The IOPC recommends that Gloucestershire Constabulary should provide training to all neighbourhood policing team officers to ensure improved awareness of antisocial behaviour and the use of community protection warning letters, community protection notices and antisocial behaviour injunctions, as well as …
Recommendation - Hertfordshire Constabulary, April 2026
The IOPC recommends that Hertfordshire Constabulary take steps to assure itself that police officers and staff likely to be involved in the handling of cross-border missing person investigations, especially those where mental health and safeguarding risks are present, are aware …
Operation Hotton recommendations - Metropolitan Police Service, September 2021
The IOPC recommends that the MPS should build on the positive steps it is taking to eradicate sexism and misogyny from the police force, which should include committing publicly to a position of zero-tolerance. This should include reviewing its current …
Investigation into police contact before a death - Northumbria Police, January 2022
The IOPC recommend that Northumbria Police should ensure that all domestic violence crimes are being investigated by suitably trained officers and at an area commend level and investigated by CID teams and using a combination of PIP 1 and PIP …
Teenager took his own life after calling police for assistance – Kent …
The IOPC recommends that Kent Police should ensure that where computer systems are upgraded and updated, that default settings are checked and the operators of those systems are made aware of the changes to settings before use. This follows an …
Recommendations - South Wales Police, July 2022
The IOPC recommends the National Police Chiefs’ Council (NPCC) shares the learning from this IOPC investigation with force custody leads, asking them to take steps to ensure: Custody staff understand that the Prisoner Escort and Custody System (PECS) is a …
Recommendations - South Wales Police, July 2022
The IOPC recommends the NPCC (as holders of the national portfolio for custody and detention) provide guidance to all police forces highlighting: The Prisoner Escort Custody Service (PECS) is a stand-alone system which does not interface with any police systems. …
Investigation into police pursuit and subsequent road traffic incident - Metropolitan Police …
The IOPC recommends the Metropolitan Police Service should ensure that police drivers are aware of their responsibilities under relevant policy and guidance in relation to the level of speed and drive in accordance with driver training at all times, in …
Investigation into police pursuit and subsequent road traffic incident - Metropolitan Police …
The IOPC recommends that the Metropolitan Police Service ensure that all police drivers are aware that drivers of an MPS vehicle cannot use a handheld airwave radio legally unless the handsfree option is being used and that training covers this …
National recommendations relating to 'Wayne Couzens failures' - National Police Chiefs' Council …
The IOPC recommends that the College of Policing reflects on the learning coming from this investigation, and in consultation with relevant practitioners and experts, considers whether any changes to existing Authorised Professional Practice, other guidance, or training, are needed to …
Recommendations - Hampshire Police, June 2023
The IOPC recommends that Hampshire & IOW Constabulary should review the training provided to officers to ensure they clearly understand their powers of seizure under the Animal Welfare Act 2006, including the procedures that should be followed when exercising such …
Road traffic collision shortly after police pursuit – Metropolitan Police Service, March …
The IOPC recommends the Metropolitan Police Service should ensure that police drivers are aware of their responsibilities under relevant policy and guidance in relation to the level of speed and drive in accordance with driver training at all times, in …
Road traffic collision shortly after police pursuit – Metropolitan Police Service, March …
The IOPC recommends that the Metropolitan Police Service ensure that all police drivers are aware that drivers of an MPS vehicle cannot use a handheld airwave radio legally unless the handsfree option is being used and that training covers this …
Recommendations - Norfolk and Suffolk Constabularies, October 2024
The IOPC recommends that Norfolk and Suffolk Constabularies review and update, where relevant, their force guidance and training on the role of the National Police Air Service (NPAS) during pursuits to ensure it is aligned with national guidance. The training …
Man injured during restraint and arrest - Thames Valley Police, March 2018
Recommendation to Thames Valley Police Thames Valley Police should review its training to ensure that it is providing officers with clear advice on what constitutes a head injury and when immediate medical advice must be sought and/or when a detainee …
Man dies on way to custody - Thames Valley Police, November 2017
Evidence in this case suggests that all officers could have benefited from more comprehensive and clear advice regarding conferring and the use of body-worn videos. The IOPC recommends that Thames Valley Police (TVP) considers how it can ensure that first …
Police contact with a man and a woman before he murdered her …
When officers or staff move to a different role they should be given training and support to carry out the new role. Transition training and support should also be made available.
Recommendations - Surrey Police, April 2020
The IOPC recommends that Surrey Police training and/or policy on the use of mobile data terminals is reviewed to ensure officers are aware of the practical uses this piece of equipment can provide. Surrey Police provide a three hour training …
Police response to a domestic incident - Essex Police, September 2020
The IOPC recommends that Essex Police should review the quality and effectiveness of its initial and refresher domestic abuse training for frontline officers with specific reference to: - the responsibility of officers to take positive action (including arrest of perpetrator) …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police consider updating force policy to robustly cover checking cells specifically for the purpose of detainee safety. Force policy should be clearly communicated to custody staff with training and oversight to ensure that cell checking …
Recommendations - Cleveland police, April 2020
The IOPC recommends that Cleveland Police review the working practices used in custody, specifically in relation to CCTV observations, to ensure that the principles set out in the Authorised Professional Practice (APP) are followed. This could be reinforced by additional …
National recommendation - National Police Chiefs' Council, February 2021
The IOPC recommends that the National Police Chiefs’ Council (NPCC) takes steps to ensure that all police forces provide training to officers and staff who regularly come into contact with members of the public, whether face-to-face or by some other …
Recommendations - Kent Police, November 2020
The IOPC recommends that Kent Police provides their operational employees with clarity on the different definitions of the term ‘vulnerable.’ There are two strands to this recommendation: - Kent Police to ensure officers and staff sufficiently understand how to assess …
Recommendation - Norfolk Constabulary, March 2021
The IOPC recommends that Norfolk Constabulary devise a training programme or incorporate into existing training the content of the revised Home Office Guidance (Conduct, Efficiency and Effectiveness: Statutory Guidance on Professional Standards, Performance and Integrity in Policing)2020 regarding off duty …
NAO audit recommendations(53)— showing 50 strongest matches
Government's general grant schemes
To improve grant practitioners' capability, the Grants Management Function should work with departments to: (e) promote take-up of the learning and training opportunities available, including mandating the managers of large, complex or novel grant schemes to have achieved the grants …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should continue work to clarify opportunities for career progression within the department and support staff to navigate them. Staff still lack clarity around career progression and capability requirements in the merged organisation. FCDO has developed a new capability framework …
Accepted
Increasing the capacity of the prison estate to meet demand
MoJ should combine thinking on policy objectives for the prison estate and improved evidence of different approaches to develop a long-term strategy to improve the resilience of the estate. It should: set out how it will ensure it has the …
Accepted
Civil service workforce: Recruitment, pay and performance management
Each department?s HR director should report regularly to the department?s executive committee on the number and grade breakdown of staff identified as underperforming. This should include reporting on what happens after staff have been identified as underperforming, to help departments …
Accepted
Managing central government property
g) The OGP should: ? support departments to improve maturity of property skills; and ? monitor departments? level of skills against the functional standard to ensure they are being met across government; collect data on the impact and benefits of …
Accepted
Investigation into the management of the Holocaust Memorial and Learning Centre
To help manage the emerging risks, we recommend that the Department: c ensure that senior programme and project leaders have the necessary skills or have completed appropriate training, to help comply with IPA guidance which states that SROs are expected …
Accepted
Evaluating government spending
k) work with the Policy Profession to deliver plans to assess and improve evaluation literacy for policy professionals and analysts across government.
Accepted
Department for Work and Pensions Annual Report and Accounts 2020-21
Ensure that tackling fraud and error is part of claimant-facing staff job design. This should be built into job descriptions, with the right supporting tools andincentives, so that front-line staff recognise that tackling fraud and error is an integral part …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should accelerate its work on culture change. Now that the core elements of integration have been mostly delivered, FCDO should focus on working with teams in the UK and overseas to build cultures that align with FCDO?s strategy and …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 12: Future versions of the modelling would be improved by greater consultation and by taking better account of the factors that could limit the expansion of education and training, and of any reductions in service that might result from …
Accepted
Civil service workforce: Recruitment, pay and performance management
The Cabinet Office should work with departments to help them assess the effectiveness of their own performance management systems, including line manager/employee ratios and approaches to performance-related pay. These assessments should consider the requirements of the civil service performance management …
Accepted
Resilience to flooding
d take realistic account of staff resource constraints when setting out the objectives, scope and ambition of the next capital programme and the impacts on whole-life asset management
Accepted
Digital transformation in government: addressing the barriers to efficiency
CDDO should e) review what departments can realistically achieve in terms of closing their skills gap and keep the scope of Roadmap activities under continuous review to ensure it matches available resources, accepting that prioritisation may be necessary
Accepted
Digital transformation in government: addressing the barriers to efficiency
CDDO should c) continue to push for central reforms in the way digital change is justified, funded and procured and work with policymakers, who often do not have the digital skills to understand how digital services work, to improve policy-making …
Accepted
Digital transformation in government: addressing the barriers to efficiency
CDDO should b) increase its capability-building through formal training and mentoring support to help senior non-specialist leaders develop their understanding of government's operating environment and the constraints posed by legacy data and systems
Accepted
Developing workforce skills for a strong economy
Support the Unit for Future Skills to focus on the most important areas of forecasting and assess whether the Unit is effectively influencing stakeholders to use the intelligence and insights it generates
Accepted
Developing workforce skills for a strong economy
Consider specific issues relating to older workers who form a growing proportion of the workforce, including current and future skills gaps, barriers to participation in skills training and how these barriers could be addressed. DfE should work with DWP in …
Accepted
Developing workforce skills for a strong economy
Strengthen oversight of government?s portfolio of skills initiatives by regular reporting against performance metrics from across departments to the Labour Market Steering Group; and clarifying how different cross-government forums fit together. DfE should work with the Cabinet Office in particular …
Accepted
Developing workforce skills for a strong economy
Work with mayoral combined authorities and other local bodies to establish how it can achieve the 2030 Levelling Up skills mission most effectively, and report regularly on whether it is on track. DfE should work with DLUHC in particular on …
Accepted
Developing workforce skills for a strong economy
Develop a strategy and supporting implementation plan for achieving its objectives on workforce skills, building on the approach set out in the Skills for Jobs white paper. This should set out: ? how different parts of the system, and different …
Accepted
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
To maximise the value of AO assessments in supporting good-quality decision-making, accounting officers should: ? regularly identify those areas of the AO assessment that prove the most challenging to complete, and identify what additional support may be required for staff
Rejected
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
To maximise the value of AO assessments in supporting good-quality decision-making, accounting officers should consider sharing AO assessments with those parts of their organisation that need to understand departmental risk and spending (such as the investment committee) and the governance …
Rejected
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
HM Treasury should remind accounting officers of the need to fulfil their responsibility to publish summary AO assessments and ensure that these are easily accessible through its GOV.UK website to improve transparency.
Accepted
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
HM Treasury should as part of any wider governance review provide greater clarity on how AO assessments fit within the wider governance and accountability framework, including the IPA?s reviews of major programmes. This should also set out when AO assessments …
Accepted
Accounting Officer assessments: improving decision-making and transparency over government’s major programmes
HM Treasury should enhance its support to accounting officers and departments by, for example, completing an annual review of the quality of AO assessments to help identify good practice, providing training and facilitating conversations across government on what ?good? looks …
Partially accepted
Evaluating government spending
To deliver a step-change in the evaluation capacity and capability of analysts and policy staff, the Analysis Function should: j) work with the CGEG, departments and the Cabinet Office to assess government’s specialist evaluation capacity and capability and agree a …
Accepted
Evaluating government spending
To raise standards and support departments in consistently meeting evaluation requirements, the Analysis Function and the Evaluation Task Force should work with others in the evaluation community of practice (including CGEG and government professions) to make available in a single …
Accepted
Environment Agency Annual Report and Accounts 2023-24
maintaining the environment ? through appropriate resourcing and training, and broader leadership which promotes good data quality and continuous improvement ? for improvements in financial management to be sustained over the long-term
Accepted
The UK border: Implementing an effective trade border
By September 2024 the Cabinet Office and Defra, working with the Northern Ireland Civil Service (NICS), should consider how they can provide ongoing support and advice to the NICS in the context of NI?s unique access to the UK and …
Accepted
The UK border: Implementing an effective trade border
By September 2024, the Cabinet Office should agree with Border Force and with the Northern Ireland authorities a plan for ensuring compliance with new rules being introduced through the Windsor Framework and the Command Paper.
Accepted
The UK border: Implementing an effective trade border
The Cabinet Office should ensure it has published in good time clear guidance for traders on the arrangements necessary to implement the next phases of the Windsor Framework and the Command Paper.
Accepted
The UK border: Implementing an effective trade border
The Cabinet Office, working with Defra, HMRC and the Home Office, should, by July 2025, have a plan in place to monitor compliance with the new controls. This should include any necessary reprioritisation of border resources and management of risks …
Partially accepted
The UK border: Implementing an effective trade border
Defra, HMRC and the Home Office, working with the devolved administrations, should take action as soon as they can to ensure full controls are operating at all ports, and the Cabinet Office should provide central oversight and coordination of this …
Partially accepted
Implementing statutory biodiversity net gain
be proactive in co-ordinating opportunities for best practice to be shared and adopted quickly, particularly among local authorities.
Accepted
Customer service
[On protecting tax revenue:] j. HMRC should look at cases of taxpayers failing to take reasonable care, to understand the main reasons and identify whether there are changes it can make to its services and systems to reduce occurrences
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should implement a revised internal communications and engagement strategy setting out its plan to deliver future organisational improvement, incorporating where appropriate the remaining elements of integration. This will help to address the uncertainty and remaining concerns which are affecting …
Accepted
Progress with the merger of the Foreign & Commonwealth Office (FCO) and …
FCDO should complete its work to align allowances as a matter of urgency, and should also prioritise work to resolve remaining issues with the basics of HR, IT and corporate services provision.
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 15: Ahead of the next version of the LTWP, NHSE modellers should consult further with a wide range of stakeholders, including Royal Colleges, healthcare providers and other health bodies about the appropriate substitution rates to use when meeting demand …
Accepted
The asylum and protection transformation programme
The Home Office should: put in place a performance measurement system for the Programme that gives a comprehensive overview of performance across all of its objectives. In particular, in its programme reporting, it should include measures of the flexibility and …
Accepted
Progress with trade negotiations
DIT should work with other departments, including Defra, FCDO and BEIS, to further embed across government the trade negotiating capacity and capability that it has built over the past few years. For example, to improve staff retention, DIT should continue …
Accepted
Investigation into underpayment of State Pension
h) improves training on and management of complex State Pension cases. For example, for the duration of the LEAP exercise it should regularly consider what additional training, guidance and case studies of complex cases its State Pension case workers need, …
Accepted
The challenges in implementing digital change
The new Central Digital and Data Office, along with the Government Digital Service and the Cabinet Office, should work to provide clear leadership for this agenda, in particular: a) revise existing training programmes to better equip and train all decision?makers …
Accepted
Improving the performance of major equipment contracts
e) The Department should do more to keep key personnel in place on contracted programmes for as long as is needed to meet specific milestones. SROs and senior members of their team are crucial to the delivery of contracted programmes …
Accepted
Central oversight of arm’s-length bodies
The Cabinet Office and departments should develop and strengthen centres of ALB expertise and support them with organising events, training and sharing of good practice.
Accepted
Central oversight of arm’s-length bodies
The Cabinet Office should set out common standards for what good departmental sponsorship arrangements look like, and work with departments to ensure sponsorship teams have the right capability and sufficient capacity. It should monitor how this is adopted by departments …
Accepted
The adult social care market in England
b) develop a workforce strategy, in line with its previous commitments, to recruit, retain and develop staff, aligned with the NHS People plan where appropriate;
Accepted
Immigration enforcement
c) Develop a common understanding of ‘harm’, so that all staff are confident they see harm in a consistent way for their area. Immigration Enforcement’s ongoing work to assess current and emerging threats helps teams focus on harm, but there …
Accepted
Digital transformation in the NHS
d) Alongside the implementation plan, develop specific resources and plans for high-risk issues: • Establish a resource to provide bespoke support to trusts in managing the adaptive change required for digital transformation. • Prepare a communication plan to ensure trusts, …
Partially accepted
BBC Studios
• BBC Studios’ management of its staff, development of organisational capacity and delivery of cultural change.
Accepted
Department for Work and Pensions annual report and accounts 2018-19
• raise awareness among Housing Benefit claimants of the change in the ‘abroad’ eligibility rule to reduce this cause of fraud and error, learning from the reduction achieved in Pension Credit.
Accepted
PHSO ombudsman recommendations(2)
Ignoring the alarms: How NHS eating disorder services are failing patients
Health Education England should review how its current education and training can address the gaps in provision of eating disorder specialists we have identified.
Ignoring the alarms: How NHS eating disorder services are failing patients
The General Medical Council (GMC) should conduct a review of training for all junior doctors on eating disorders.
Victims' Commissioner recommendations(1)
IMB annual reports(115)— showing 50 strongest matches
Stoke Heath (2021)
HMP/YOI Stoke Heath faced significant challenges during the Covid-19 pandemic, leading to a restricted regime with prisoners locked in cells for extended periods, impacting their wellbeing and rehabilitation. Despite this, the IMB found the prison to be safe, with well-led healthcare services and positive staff-prisoner relationships. Key concerns include severe funding cuts to education and vocational training, an inadequate heating system, and the detrimental impact of the restrictive regime and blended learning on purposeful activity and rehabilitation.
PRISON
Key concerns
Wetherby (2022)
HMYOI Wetherby faced significant challenges during the reporting year, including persistent staffing shortages which severely impacted the regime, leading to limited time out of cell, particularly in evenings. The Board noted concerning levels of violence, self-harm, and the continued problem of weapon creation. Additionally, there were unacceptable delays in transferring young people with complex mental health needs and significant evidence of racism. Despite these challenges, the Board commended positive staff-young person relationships, good physical healthcare provision, and welcome investments in the estate and engaging educational programs.
PRISON
Key concerns
Aylesbury (2020)
Aylesbury YOI, operating with a reduced population of 209 due to special measures, successfully improved its safety and operational performance, leading to the withdrawal of its special measures status. Despite positive developments like improved staff-prisoner relationships and infrastructure upgrades, significant concerns persist regarding the amount of time prisoners spend locked in cells, the quality of purposeful activity, and ongoing staffing and estate issues. The report also highlights challenges in addressing equality and diversity, and the impact of long segregation stays on young prisoners' wellbeing.
PRISON
Key concerns
Oakwood (2021)
HMP Oakwood navigated the COVID-19 pandemic under a strict 22-23 hour lockdown regime, with staff showing exemplary commitment in maintaining a safe environment and humane treatment. Despite these efforts, the regime severely limited education, purposeful activity, and access to services, leading to concerns about sentence progression and mental health impacts. Key issues included the poor performance of the education provider Novus, persistent problems with prisoner property transfers, and challenges in managing transfers of vulnerable prisoners without appropriate medical information or COVID-19 testing.
PRISON
Key concerns
Bristol (2021)
HMP Bristol successfully managed Covid-19, implementing strong infection control and a good vaccination programme. The prison saw significant improvements in accommodation and the general environment, alongside a reduction in self-harm and violence. However, the Board remains concerned about inconsistent key work delivery, staffing shortfalls, persistent issues with disability access, and the appropriate placement of vulnerable prisoners.
PRISON
Key concerns
Brinsford (2021)
Despite a severely restricted Covid-19 regime, HMP/YOI Brinsford is deemed a safe prison where prisoners are treated fairly. While incidents of violence, self-harm, and substance misuse have reduced due to lockdown, persistent issues include delays in transferring prisoners with mental health needs and an education contract that largely failed to meet prisoner requirements for much of the reporting period.
PRISON
Key concerns
Werrington (2021)
HMYOI Werrington operated with significant challenges during the reporting year, marked by the ongoing pandemic, major refurbishment, and a sharp increase in violence and disruption in the latter months. The Board raised serious safety concerns, noting restricted time out of room and staff shortages led to inhumane treatment. While healthcare was proactive and efficient, education struggled amidst disruptions, and the Board highlighted issues with the use of Rule 49 and long remand waiting times.
PRISON
Key concerns
Thorn Cross (2022)
HMP/YOI Thorn Cross experienced a challenging year due to the pandemic and staffing issues but maintained a safe and humane environment. The Board found the prison's rehabilitative culture and healthcare provision to be strong, with positive staff-prisoner relationships. Key concerns include budget pressures, delays in high-risk transfers, persistent property issues, and the need to improve data collection on protected characteristics and reduce absconds.
PRISON
Key concerns
Young Offender Institutions (YOIs) in England (2021)
This national IMB report covers Young Offender Institutions (YOIs) in England from June 2020 to August 2021, a period heavily shaped by the Covid-19 pandemic. While some positive developments were noted, such as improved reception processes and generally lower self-harm, significant concerns persisted. These included limited time out of cell, insufficient education, and critical delays in mental health transfers and post-release support from local authorities, all exacerbated by pandemic restrictions.
PRISON
Key concerns
Woodhill (2022)
HMP Woodhill faced significant challenges during the reporting year, primarily driven by severe staffing shortages which restricted the regime and impacted prisoner safety, wellbeing, and access to services. While there were positive efforts in areas like Covid-19 response and family contact initiatives, high levels of violence, prolonged segregation, and inadequate progression opportunities remained key concerns. The IMB judges that the prison requires improvement, particularly in addressing staffing, regime delivery, and resettlement support.
PRISON
Key concerns
Dungavel House IRC (2021)
Dungavel IRC was well-managed by both GEO and Mitie throughout 2021 despite COVID-19 challenges, treating residents fairly and safely. Healthcare provision was good, and a relaxed regime with ample activities was maintained due to low resident numbers. Key concerns included IMB member recruitment, high CSU temperatures, the need for a disability officer, and unresolved issues like staff negotiation training and parking.
IRC
Key concerns
Swinfen Hall (2022)
HMP/YOI Swinfen Hall, a YOI and Category C training prison, held 583 prisoners during the reporting year. The Board noted positive progress in safety initiatives and equality, diversity, and inclusion. However, significant concerns remain regarding slow responses to prisoner property and complaints, insufficient purposeful activity places, and delays in offender management. Healthcare provision, particularly night cover and mental health staffing, also raises concerns.
PRISON
Key concerns
Stoke Heath (2022)
HMP/YOI Stoke Heath maintained a safe and positive environment during the reporting year ending March 2022, despite ongoing Covid challenges. Key positives included improved in-cell telephony, good routine GP access, and declining use of force. However, significant concerns persist regarding the slow restoration of the key worker scheme, inadequate vocational training and resettlement support, and persistent delays in dental care and access to mental health beds.
PRISON
Key concerns
Wormwood Scrubs (2022)
HMP Wormwood Scrubs experienced a slow return to normal regime during the reporting year ending May 2022, impacted by Covid-19 restrictions and persistent staff shortages. The Board noted some improvements in reception and healthcare provision but raised significant concerns regarding the poor quality of food, high number of cancelled hospital appointments, and long delays for mental health transfers. Key challenges included disproportionate use of force against Black prisoners, a largely closed library and depleted education, and a patchy key worker scheme.
PRISON
Key concerns
Berwyn (2022)
HMP Berwyn continues to be a safe establishment, though it faces significant challenges from staffing shortages, which impact regime delivery, purposeful activity, and key work. The Board notes improvements in resettlement outcomes and a reduction in serious assaults, alongside robust use of force data collection. Key concerns remain the long waiting times for dental care and mental health transfers, as well as the poor timeliness in responding to prisoner complaints.
PRISON
Key concerns
Lindholme (2023)
HMP Lindholme successfully transitioned to a full regime post-Covid, with many prisoners feeling safe, though issues like overcrowding and double-occupancy cells persist. Healthcare needs are generally met, but access challenges remain. The Board highlights concerns regarding property issues, the complaints system, and the need for improved resettlement and IPP prisoner progression.
PRISON
Key concerns
London STHF (2023)
This report covers the London Short-Term Holding Facilities at Heathrow and City Airports, and reporting facilities Becket and Eaton House for the reporting year ending January 2023. The Board found that while holding rooms generally provide a safe environment and most inductions were done well, significant concerns persist around excessive lengths of stay, inadequate facilities, and lack of access to internet and medication. Recommendations target the Minister, Home Office, Border Force, Mitie Care & Custody, and Clearsprings to address these issues, many of which are repeated from previous years.
PRISON
Key concerns
Five Wells (2023)
HMP Five Wells, a Category C prison, opened in February 2022 and housed 1200 prisoners by March 2023, below its operational capacity of 1680. The IMB noted successes such as positive visitor feedback and streamlined safeguarding, but raised significant concerns including widespread illicit items, severe staffing shortages, and numerous design flaws in the new build. Key areas needing development involve consistent regime application, improved food and canteen services, and the re-establishment of resettlement-focused programmes like ROTL.
PRISON
Key concerns
Littlehey (2023)
HMP Littlehey is a Category C training prison for men convicted of sexual offenses, holding 1,171 prisoners. The Board commended the prison for its generally safe environment, compassionate end-of-life care, and excellent PE regime. Key concerns include persistent overcrowding due to shared cells, long waiting times for specialist healthcare, and significant issues with managing prisoner property transfers between prisons. The report also highlights the over-representation of Black and Muslim prisoners in adjudications and use of force incidents, and ongoing problems with heating infrastructure and the use of temporary freezers.
PRISON
Key concerns
Guys Marsh (2023)
The Independent Monitoring Board at HMP Guys Marsh noted positive developments including sufficient organisational support for safety, the appointment of a neurodiversity support manager, and a seamless transition to a new healthcare provider. However, significant concerns remain regarding persistent drug and alcohol use driving violence, ineffective risk management plans, and unacceptably high prisoner-on-prisoner assaults. The Board also highlighted issues with accommodation standards, a long dental waiting list, and underutilised education and work provisions.
PRISON
Key concerns
Isis (2023)
HMP/YOI Isis, a YOI and Category C training prison, experienced a marked increase in violence and self-harm during 2023, attributed partly to a younger demographic and increased prisoner mixing. Staffing shortages and a high number of 'ineffective' staff consistently impacted regime delivery, education, and healthcare access. The Board highlighted persistent concerns with property management, cell cleanliness, and the limited range of rehabilitation programmes.
PRISON
Key concerns
High Down (2023)
HMP High Down, a Category C training and resettlement prison, experienced significant increases in assaults and illicit item finds during 2023, raising serious safety concerns. Staffing shortages in key work and the Offender Management Unit severely impacted regime delivery and prisoner progression. While improvements were noted in mental health transfer times and family contact, persistent issues with property loss, poor shower conditions, and limited purposeful activity for prisoners, particularly vulnerable ones, remained key challenges.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2023)
The IMB's report for Kent Coast STHF (WJF, KIU, Manston) for 2023 highlights commendable staff empathy and improved medical provisions. However, it raises significant concerns regarding the lack of clear information for detainees about their processing and length of stay, inadequate privacy for interviews, and substandard conditions in isolation units and sleeping arrangements. The Board also noted issues with facility maintenance and the inconsistent receipt of vital monitoring reports.
PRISON
Key concerns
Gatwick IRC (2023)
The Gatwick IRC experienced a deterioration in safety during 2023, marked by increased violence, assaults on staff, and a rise in use of force incidents, partly attributed to a changing detainee population. Key safeguards for vulnerable individuals, such as Rule 34 and Rule 35 assessments, were found to be insufficient or subject to unacceptable delays. The report highlighted significant concerns regarding inadequate mental health provision, unfair regime practices including prolonged lock-in times, and a lack of effective pathways for release for detainees granted bail.
IRC
Key concerns
Gatwick pre-departure accommodation (2023)
The IMB report for Gatwick Pre-Departure Accommodation for 2023 highlights concerns regarding the detention of four families, all of whose removal attempts failed. The Board questions the fairness and humanity of the process, particularly noting the trauma to children and callous treatment of a pregnant mother. Key recommendations include the closure of the PDA and prohibiting the detention of pregnant women.
PRISON
Key concerns
Heathrow immigration removal centre (2023)
The IMB report for Heathrow IRC (2023) highlights increasing safety concerns, including a rise in self-harm (180 incidents), assaults (131 detainee-on-detainee, 54 on staff), and drug finds (104). The Board expresses significant concerns over the detention of mentally unfit individuals, the dilapidated infrastructure, and the misuse of segregation units. While health needs are generally met, staffing shortages and delayed Rule 35 responses remain problematic. The report also notes repeated concerns about prolonged detention times and the need for improved resettlement pathways for those on bail.
IRC
Key concerns
Bullingdon (2020)
HMP Bullingdon, a local and resettlement prison, experienced high overcrowding and staffing challenges, with a significant proportion of inexperienced officers. While physical health services were generally good and some educational outcomes improved, violence and drug finds remained high, and mental health provision, particularly counselling, was inadequate. The COVID-19 pandemic severely restricted the regime, leading to prolonged cell confinement, but the prison successfully prevented widespread infection. Persistent issues include inadequate reception facilities for vulnerable prisoners, property loss, and maintenance backlogs, while resettlement outcomes remain patchy.
PRISON
Key concerns
Dartmoor (2020)
HMP Dartmoor, a Category C training prison, faces significant challenges due to uncertainty about its 2023 closure, leading to under-investment in infrastructure and impacting staff morale. The COVID-19 pandemic severely restricted the regime, reducing time out of cell and exacerbating mental health issues, despite staff efforts to maintain safety and welfare. Key concerns include inadequate mental health provision, substance misuse, and deficiencies in resettlement support, as Dartmoor is not funded as a dedicated resettlement prison.
PRISON
Key concerns
Rye Hill (2021)
The IMB report for HMP Rye Hill (April 2020 – March 2021) details the prison's operation under COVID-19 restrictions, maintaining a safe and humane environment with commendations for case management and a prompt vaccination program. Key challenges included the significant impact of restrictions on IPP prisoner progression, insufficient mental health transfer places, and the need for broader education courses. The report also raised concerns about equality monitoring, the high threshold for upholding discrimination complaints, and ongoing difficulties with resettlement accommodation and Probation Service arrangements for released prisoners.
PRISON
Key concerns
Peterborough (Women) (2021)
The reporting year was dominated by the Covid-19 pandemic, during which HMP Peterborough (Women) managed the emergency well, leading to significant improvements in safety outcomes. However, the restrictive regime severely impacted women's wellbeing and rehabilitation. Key concerns remain regarding national support for complex needs women, the effectiveness of the key worker system, and the need to adapt the regime better to women's specific needs.
PRISON
Key concerns
Winchester (2021)
HMP Winchester successfully navigated the Covid-19 pandemic, preventing internal outbreaks and earning commendation for its management. Despite this, the prison continues to face significant challenges including high levels of violence, severe regime restrictions, and ongoing issues with overcrowding and the dilapidated prison estate. While healthcare provision has improved and ACCT cases have reduced, the IMB raises multiple concerns regarding the inhumane out-of-cell time, inadequate facilities for vulnerable prisoners, and a lack of funding for critical improvements.
PRISON
Key concerns
Birmingham (2021)
HMP Birmingham has shown significant improvement in safety and stability under new leadership, making it the safest it has been in years, despite challenges posed by the Covid-19 pandemic. Healthcare provision is good, and peer support systems are strong. However, key concerns persist regarding the inhumane nature of prolonged in-cell lock-up, the high levels of use of force, and persistent issues with long stays in segregation. Other areas needing development include support for homelessness on release, addressing learning difficulties, and ensuring equity in the IEP scheme.
PRISON
Key concerns
Ashfield (2021)
HMP Ashfield is judged to be a well-managed Category C prison for sex offenders, maintaining high standards and humane treatment despite significant COVID-19 challenges. The prison effectively managed the pandemic, achieving low infection rates and progressively easing restrictions to maximize purposeful activity. Key concerns include persistent difficulties in securing suitable accommodation for released prisoners, a severe reduction in offending behaviour programme places, and issues with mental health support and equality and diversity monitoring.
PRISON
Key concerns
Buckley Hall (2021)
The reporting year at HMP Buckley Hall (Aug 2020 - July 2021) was largely defined by Covid-19, leading to significant operational challenges and a restrictive regime. Despite these difficulties, the IMB judged the prison to be safe, with dedicated leadership and staff, and good healthcare provision. Key concerns persist regarding prisoner progression, funding for new initiatives, and some basic decency issues such as secure in-cell medication storage and shower quality.
PRISON
Key concerns
Wayland (2021)
HMP Wayland's reporting year was dominated by the Covid-19 pandemic, leading to a severely restricted regime with prisoners often locked in cells for up to 22 hours daily, and a virtual halt to education and purposeful activity. The Board raised significant concerns about critically low staffing levels and inexperience, alongside a substantial minority of prisoners feeling unsafe and declining trust in staff. While improvements were noted in use of force management and new drug detection methods, the Board struggled to monitor healthcare due to exclusion from meetings.
PRISON
Key concerns
Aylesbury (2021)
This report covers a year dominated by the Covid-19 pandemic at Aylesbury YOI, which saw a reduced prisoner population of around 209. Despite a severely curtailed regime and poor education provision, the prison maintained stability, low infection rates among prisoners, and provided daily showers and exercise. Key concerns include the lack of mental health beds, the weakening of the key worker scheme, and the risk that post-pandemic priorities will shift from prisoner outcomes to risk management as population numbers increase.
PRISON
Key concerns
Guys Marsh (2021)
HMP Guys Marsh, a Category C training prison, navigated a challenging year (Dec 2020 – Nov 2021) under a restrictive "red regime" due to COVID-19. While recording no deaths in custody and a 20% drop in self-harm, concerns persisted regarding a significant increase in staff assaults, high mental health transfer waiting times, and problems with key working and purposeful activity due to staffing pressures and regime restrictions. The Board highlighted the need for improved staff retention, better IT systems, enhanced resettlement provisions, and a more consistent application of incentive schemes.
PRISON
Key concerns
Usk and Prescoed (2021)
HMP Usk (Category C) and HMP Prescoed (Category D) operated under significant Covid-19 restrictions during the reporting period, leading to an atypical regime. Despite these challenges, the Board considers them to be safe, well-run prisons with low levels of violence and self-harm, effectively managed by staff. Key achievements include the early rollout of vaccinations and successful maintenance of off-site work placements for Prescoed prisoners, though concerns remain regarding education funding, OASys document quality, staffing retention, and telephone access.
PRISON
Key concerns
Swaleside (2022)
HMP Swaleside experienced a challenging year (May 2021 - April 2022), marked by severe staff shortages, a restricted regime due to Covid-19, and a high number of deaths in custody and self-harm incidents. The Board highlighted significant concerns regarding staffing, the impact of new prisoner allocations, and the lack of essential equipment like body-worn cameras. Positive developments included excellent education provision, effective outreach services, and improvements in discrimination incident reporting, though overall challenges to prisoner welfare and safety persist.
PRISON
Key concerns
Erlestoke (2022)
The report covers HMP Erlestoke from April 2021 to March 2022, a period significantly impacted by Covid-19 restrictions that limited out-of-cell time. Despite challenges like staff shortages and high turnover, the Board found prisoners to be relatively safe, though violence increased and self-harm remained high. Key concerns include delays in transfers, inadequate mental health provision, and the slow pace of infrastructure improvements.
PRISON
Key concerns
Winchester (2022)
HMP Winchester, a complex local B/C category prison, continues to face significant challenges, including high levels of violence and self-harm, a restricted regime with prolonged cell confinement, and critical issues with its outdated building infrastructure. While staff efforts to provide humane treatment are commendable, severe staffing shortages and high turnover undermine consistency and effective key working. The IMB highlights persistent problems such as cell overcrowding, inadequate CCTV, and vermin infestation, which compromise safety and wellbeing despite some recent positive trends in violence reduction and effective pandemic management.
PRISON
Key concerns
Isle of Wight (2021)
HMP Isle of Wight operated under a continued restricted regime in 2021 due to Covid-19, impacting daily life and increasing tensions. While the Board praised staff efforts and noted positive developments in healthcare, equality, and complaint handling, significant concerns persisted regarding the dilapidated laundry, unhygienic meal services, and underfunded estate repairs. Staffing shortfalls in mental health and probation services critically hampered prisoner support and progression, alongside challenges posed by the delayed transfer of Category C prisoners.
PRISON
Key concerns
Werrington (2022)
The IMB has grave concerns about HMYOI Werrington, deeming it unsafe for both young people and staff due to a significant increase in violence, including assaults and weapon making. Low staffing levels and sickness led to a severely restricted regime, particularly at weekends, with young people spending excessive time locked in their rooms. Education provision was inadequate, and staff-young person relationships deteriorated.
PRISON
Key concerns
Wayland (2022)
The IMB for HMP Wayland concludes that the prison continues to be failed by the Prison Service and the government across multiple areas, from infrastructure maintenance to adequate staffing and training. The report notes a decline in the quality and effectiveness of prisoner treatment, with key concerns including prisoner safety, deteriorating accommodation, and inadequate resettlement support. While some positive initiatives have begun, the Board finds that fundamental issues persist and require urgent, comprehensive intervention.
PRISON
Key concerns
Lincoln (2023)
HMP Lincoln, a Category B prison, experienced a decrease in self-harm incidents and drug finds during the reporting period, alongside generally positive staff-prisoner relationships. However, significant concerns persist regarding the length and quality of maintenance work by Amey, and the inadequate access to specialist mental health facilities. Other key challenges include the impact of increasing operational capacity, difficulties for transient prisoners accessing education, issues with property transfers, and unsuitable infrastructure for vulnerable prisoners.
PRISON
Key concerns
Dungavel House IRC (2022)
Dungavel House IRC maintained a safe and humane environment in 2022, with sufficient staffing and a positive staff-detainee relationship fostering a relaxed regime. While healthcare provision was good and significant efforts were made for purposeful activity, concerns persist regarding the uncertainty of detainees' futures and the need for improved roof access prevention. Repeated recommendations, such as staff negotiation training and CSU temperature control, remain ongoing issues.
IRC
Key concerns
Hindley (2023)
HMP/YOI Hindley, a Category C training and resettlement prison for adult males and young adults, operated near its 600 operational capacity during the reporting period. The Board noted positive developments in leadership presence, communication, and some healthcare provision, which was rated good by HMIP. However, significant concerns persist, particularly regarding escalating violence, high self-harm rates (up 87%), and widespread drug availability. Persistent staff shortages lead to redeployment, impacting purposeful activity, key worker sessions, and overall regime delivery. The Board also highlights issues with outdated accommodation, delays in adjudications, and the need for improved support for complex mental health needs and disabled prisoners.
PRISON
Key concerns
Holme House (2023)
HMP Holme House, a Category C prison, experienced a challenging year ending December 2023, marked by increased violence, use of force, and significant issues with building disrepair and illicit items. While healthcare services notably improved and purposeful activity places expanded, staffing shortages impacted resettlement and Ofsted rated all five inspection areas as 'requires improvement'. The Board highlights the need for urgent attention to infrastructure, safety, and addressing the impact of a growing young adult population.
PRISON
Key concerns
Chelmsford (2024)
HMP Chelmsford, a category B local prison, faced significant challenges during the reporting year ending August 2024, particularly with overcrowding affecting 69% of its population and leading to poor conditions in older wings. While the prison saw a reduction in self-harm incidents towards the end of the year and staff were commended for managing gym facilities, use of force incidents increased, and access to healthcare remained a major concern with substantial waiting times. Processes for safeguarding prisoner property and approving telephone PINs were consistently problematic, hindering rehabilitation and family contact, although the introduction of the Launchpad system was a notable success.
PRISON
Key concerns
Kirkham (2023)
HMP Kirkham faced unprecedented challenges in 2023, primarily due to the Temporary Presumptive Recategorisation Scheme (TPRS) which led to a significant influx of prisoners and placed immense pressure on staff, resources, and the prison's resettlement-focused regime. While the Board noted staff's resilience and improvements in some areas like healthcare waiting times and new facilities, key concerns included increased assaults, persistent illicit substance issues, and significant disruption to purposeful activities and resettlement services. Staffing shortages exacerbated these problems, leading to curtailment of activities and impacting crucial offender management processes.
PRISON
Key concerns
IMB individual recommendations(671)— showing 50 strongest matches
Exeter (2020)
Will the Governor arrange for refresher training for all prisoner-facing staff and implement arrangements for more effective monitoring of compliance and case management procedures? (See paragraph 4.2).
Governor / Director
In Progress
Bullingdon (2021)
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-19. How will the Governor ensure that these staff receive appropriate training so that they can carry out their duties effectively?
Governor / Director
Grendon (2022)
Delivery of staff training e.g. suicide and self-harm (SASH) (4.2.6).
Governor / Director
Exeter (2022)
Address the backlog in staff training and particularly control and restraint (C&R), basic, refresher and advanced training.
HMPPS
In Progress
Coldingley (2022)
In all these cases the solution must be to continue and intensify the programmes of in-house staff training and mentoring.
Governor / Director
Hewell (2023)
Is the Prison Service satisfied that training for new officers prepares them for the roles and tasks that will be expected of them? We are concerned about the length and content of training for new officers, outside aspects relating to security and control.
HMPPS
Ranby (2024)
There continues to be a high proportion of new staff with limited experience. What further steps will the Governor take to ensure these officers receive further appropriate training to enable them to carry out their duties effectively?
Governor / Director
In Progress
Ranby (2024)
The proportion of inexperienced staff has continued to increase. How does the Prison Service plan to improve the training of inexperienced staff?
HMPPS
In Progress
Preston (2024)
The Board recommends reviewing the refresher training and mentoring with regard to pro-social modelling, de-escalation and neurodiversity awareness.
HMPPS
Implemented
Exeter (2024)
Given the high proportion of prisoners with mental ill health, will the Prison Service ensure the delivery of standalone mental health training for all officers?
HMPPS
Implemented
Bullingdon (2020)
How will the governor ensure that new officers and other staff receive the training and mentoring that they need to develop in their roles, especially when the proportion of experienced operational staff is so low? And what steps can she take to retain good recruits, recognising that many factors are outside her control?
Governor / Director
Bullingdon (2020)
The recruitment of new officers over the last two years has been welcome, but the prison has lost many experienced officers, and many current members of uniformed staff have relatively little experience of working in a prison environment (see above, description of the prison, 3.1.1). How will the prison service take steps to address the issue of retaining staff, both …
HMPPS
Bullingdon (2020)
The increased number of uniformed officers during the last two years is very welcome, but it will take a long time to build up the amount of experience and knowledge that has been lost as a result of past staff cuts and subsequent attrition. How will the minister ensure that staff levels are maintained at an adequate level for the …
Ministry of Justice
In Progress
Lewes (2021)
Will the Prison Service facilitate and fund staff training that has been missed or reduced due to the Covid-19 pandemic?
HMPPS
In Progress
Lancaster Farms (2021)
To arrange for the training for new Listeners to be arranged and completed as soon as possible (paragraph 4.2.5).
Governor / Director
Implemented
Exeter (2021)
As a matter of some urgency support Governors to reduce the backlog in staff training and particularly C&R basic, refresher and advanced training.
HMPPS
Aylesbury (2021)
To make prison sentences more purposeful, and to diminish reoffending rates, set higher requirements for basic training within the whole Prison Service.
Ministry of Justice
Whitemoor (2022)
Will HMPPS give priority to improving the training and support given to prison officers in their early years in post in order to halt the haemorrhaging of staff in the first five years after their appointment?
HMPPS
Wayland (2022)
The Board recommends that prison officer training is reviewed to include deeper and more extensive training on key work and staff/prisoner relationships.
HMPPS
Wayland (2022)
The IMB at Wayland can see no effective alternative to a request to the Minister to order a complete review of the initial and development training of prison officers.
Ministry of Justice
Swaleside (2022)
The Board has seen examples of inadequacy of apprentice officer training and believes that training must at least result in those staff knowing what to expect when they arrive at their establishment. Shortage of trained staff exacerbates failings in this respect.
HMPPS
Implemented
Send (2022)
The Board would like to see provision of training to address the specific needs of female prisoners such as trauma-informed care, de-escalation and distraction techniques (5.3).
HMPPS
In Progress
Oakwood (2022)
The Board is concerned about the number and experience of new staff on the house blocks. From observing some of the case notes of key worker sessions, the quality of the reporting varies. The Board suggests that senior managers look at putting further training in place.
Governor / Director
Erlestoke (2022)
What actions will be taken to develop managers and frontline staff to increase supervision and confidence so that staff/prisoner relationships improve?
Governor / Director
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
Swaleside (2023)
The Board has raised before the inadequacy of basic apprentice officer training and believes that training must at least result in them knowing what to expect when they arrive at their establishment. Support for new officers has improved considerably at Swaleside, especially with the introduction of the mentoring system. However, this is no substitute for proper basic training.
HMPPS
Onley (2023)
What additional support can be made available to increase the number of qualified instructors, given that a lack of instructors has had an impact on available workshop spaces?
HMPPS
Kent Coast Short Term Holding Facilities (STHF) (2023)
Recommend that Board Members are given some form of personal safety training.
Home Office
Hewell (2023)
Protect staff time to deliver key work and push for national resources, including training, to make this central to the regime and culture at Hewell.
Governor / Director
Dovegate (2023)
Continue to train and develop the inexperienced staff to maintain a safe and respectful working environment for all.
Governor / Director
Bullingdon (2023)
There continues to be a high proportion of officers with limited experience. What further steps can the Governor take to ensure that these officers receive further appropriate training so that they can carry out their duties effectively?
Governor / Director
Thorn Cross (2024)
To reduce the number of staff who are overdue control and restraint training.
Governor / Director
Moorland (2024)
Can the training available to prison officers be reviewed to develop more specialised skills for the wide variety of different needs represented in the prison population?
HMPPS
In Progress
Gatwick IRC (2024)
Ensure that suitable training and support is provided so that professional interpretation services are used effectively in communications with the detained men, particularly during critical safeguards such as initial screening, and Rule 34 and 35 appointments.
NHS / Healthcare Provider
Rejected
Full Sutton (2024)
Can the Minister address concerns about the training provided for new staff, in particular their preparedness for communicating effectively and confidently with prisoners? The Board has seen examples of staff being hesitant in their dealings with prisoners. We have also heard comments from prisoners about this aspect of staff and prisoner relations, who feel that situations may be de-escalated or …
Other
Implemented
Aylesbury (2024)
Put in place centrally funded, continuing support for the newly trained officers who begin work after just ten weeks’ foundation training. The Board welcomes the new recruits, but the short length of training they undergo is insufficient to meet the many challenges on the wing. In turn, new recruits lean too heavily on the more experienced staff and this diminishes …
HMPPS
In Progress
Wymott (2025)
What steps are being taken to mentor and support the professional development of new and recently recruited officers?
HMPPS
Implemented
Wayland (2025)
We therefore make a similar recommendation this year as we have done in previous years; that more focused staff training is needed for all staff. We would now add to that general call that this should especially be for those in the new induction unit. Staff of this unit should not believe that they can solve all the problems that …
Governor / Director
In Progress
Wandsworth (2025)
The quality of new staff recruited centrally was often poor and training was inadequate. What steps are being taken to improve training and reject unsuitable candidates?
Ministry of Justice
In Progress
Swaleside (2025)
The inexperience of staff is compounded by the limited training they receive. This is not sufficient to commence employment. What steps will the Minister take to involve Governors in the recruitment process, and what is the rationale for the exclusion of Governors from the process?
Ministry of Justice
In Progress
Gatwick IRC (2021)
Training should be strengthened for frontline staff, especially in Tinsley House, to help ensure that potentially under-age individuals are identified and feel able to challenge the age imputed to them (section 4.4.3).
Governor / Director
Derwentside (2022)
To ensure all staff are trained and fully confident and competent in the governance, techniques and reporting requirements around use of force and rules 40 and 42.
Governor / Director
Wandsworth (2020)
Many of the induction meetings observed by Board members were of a low quality. The presentations were often unsympathetic and inconsistent, with inadequate slides and handouts. The Board was very disappointed that this counterproductive and poorly managed situation had continued, despite similar criticism in four previous annual reports.
Governor / Director
Onley (2020)
Greater training/support is needed for POELTs to ensure that they carry out their jobs to the best of their abilities.
Ministry of Justice
In Progress
Littlehey (2020)
When will the Prison Service ensure that prison officers are given adequate training to deal with the different needs of these groups of prisoners?
HMPPS
In Progress
Lancaster Farms (2020)
The Board notes the continued issues regarding cover arrangements for education staff who are absent due to sickness (see paragraph 9.2), and continues to observe allocation delays, prisoners sent back to their cells, and class cancellations (see paragraph 9.3).
Governor / Director
Huntercombe (2020)
To introduce or renew practical and vocational contracts so that meaningful training and work that carries a recognised international qualification can be achieved – see section 7.2.
HMPPS
Highpoint (2020)
The Board asks the governor to look proactively to appointing a suitably qualified person to the kitchen staff, who can support prisoners in obtaining an NVQ qualification, as a positive outcome of the experience gained by working there.
Governor / Director
Heathrow Short Term Holding Facility (2020)
[All holding rooms] The Detention Contractor should ensure that DCOs are trained so that they know which of the meals from different manufacturers are halal (para. 8.5).
Other
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport] The Detention Contractor should ensure that DCOs use the Big Word interpretation service for inducting non-English speaking passengers and not just assume that passengers with a smattering of English really understand what they are being told (para. 4.9).
Other
Health investigations(1163)
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
*Mental health homicide investigation legacy report into the care and … — Rec L7
Point 4 of the trust’s action plan states that the trust has delivered Historical, Clinical, Risk Management – 20 (HCR-20)training in response to the need to ensure that formalised risk assessment and management processes, including assessment of longitudinal risk over longer time periods, are in place and effectively used. However, …
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L6
The trust should monitor and review the newly-developed personality disorder initiatives to ensure that all staff, medical and otherwise, are aware of what personality disorder services are available, how to refer, and the waiting time for referral. This should include knowledge of the referral process and criteria for referring service …
south_east
*Mental health homicide investigation legacy report into the care and … — Rec L1
The trust should continue to ensure, through personal development plans and supervision, that all staff in direct contact with patients receive training in the assessment, planning and management of risk. The trust should ensure that staff receive risk assessment training and are declared competent before conducting any risk assessments. Compliance …
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xi)
The Trust and Council should introduce a course of instruction and training for mental health staff undertaking care co-ordination.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (iv)
The Trust and Council should provide a course of instruction and training for mental health staff in assessment and management of risk.
london
Independent investigation: Sidney Waller, Manchester (2008) — Rec 4
The PCT must receive assurances in relation to the clinical and managerial supervision of all staff and this must be tied in with a robust audit process and an assurance process to demonstrate that the evidence is in place and meets all the requirements of supervision.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 16
The Trust should ensure that all Trust employees are aware of the requirement to take part in clinical supervision. This requirement should be made explicit and compliance should also be audited on a regular basis.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 15
The Trust should ensure that policies and procedures are developed with: the „blue light services‟ and that arrangements are formally agreed with them; and that the revised policies and procedures are incorporated into all statutory training events; and protocols to support emergency actions are produced on a simple A4 format …
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 11
The Trust should provide training to highlight the importance, during assessment, diagnosis and treatment, of the patient‟s cultural background. This to include the requirement for: a secondary literature review to be conducted if required; specialist referral if required.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 3
The Trust should commission and develop a multi-disciplinary (MDT) and clinical skills programme specifically designed to focus on the complexity of cases with: asylum seeker status; Post Traumatic Stress Disorder in terms of assessment, diagnosis, formulation, care and treatment.
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 15
Trusts and social services should ensure that there are policies on, and staff training in, the subject of appropriate disclosure of confidential information.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
Trusts should ensure that there are policies on, and staff training in, the subject of appropriate disclosure of confidential information.
south_east
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 9
All registered health and social care practitioners mentioned in this report should receive an update for safeguarding and Mental Capacity Act training and their caseload should be subject to specialist supervision for a period of six months following the publication of this report;
north_west
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 4
All Trust and Local Authority registered health and social care professionals working in the Wigan area should receive a training update on the Mental Health Act (1983 and 2007). This training should highlight: assessment thresholds; duty of care issues for service users in inpatient settings; these to include the differentiation …
north_west
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 11
Given that new protocols have now been put in place the local Housing Associations, the Trust and the commissioners of mental health services should institute a monitoring system to ensure that: the proper roles and responsibilities of these organisation are adhered to; the protocol for sharing information is adhered to; …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 9
Access to appropriate family interventions should be available to services users under the care of the CMHT. CMHT staff should receive training and supervision in appropriate family work and interventions. The Trust should monitor the provision of this service, including using regular audits, to ensure that those individuals who might …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 7
South West Yorkshire Partnership NHS Foundation Trust should take action to ensure that the Spiritual and Pastoral Care Team, or another suitable resource, is available to raise awareness of cultural and religious issues within the clinical arena and that clinical staff have timely access to appropriate advice, consultation and supervision …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 6
South West Yorkshire Partnership NHS Foundation Trust should ensure that the aims of its Equality and Diversity policy are translated into practice in the clinical arena by: ensuring that cultural and religious issues are included in the assessment of need in a routine manner; ensuring that staff receive appropriate training …
north_east_yorkshire
Independent investigation: Bridget MaclennanElizabeth Valad, Camden — Rec 17
All mental health staff should have training in translating implicit into explicit knowledge. It would be appropriate for this to be considered specifically in training and supervision.
london
Independent investigation: Bridget MaclennanElizabeth Valad, Camden — Rec 13
Psychiatrists and other mental health professionals should receive further training in understanding and describing features of personality, independent of the specific process of diagnosing particular personality disorders.
london
An independent investigation into the care and treatment of a … — Rec Recommendation 3
The Trust should ensure that all Early Intervention in Psychosis staff are able to undertake a robust mental state examination, including using the Positive and Negative Syndrome Scale (PANSS), and are able to develop a relapse prevention plan for each client on their caseload.
south_east
An independent investigation into the care and treatment of a … — Rec R1
All Early Intervention in Psychosis staff to be able to undertake a robust mental state examination include using the Positive and Negative Syndrome Scale (PANSS) and be able to develop a relapse prevention plan for each client on their caseload.
south_east
Independent investigation report into the care and treatment of Yusuf — Rec 1
Difficult conversations took place between relatives and hospital staff as Yusuf’s family attempted to access urgent care. • All clinical teams are to be encouraged to attend simulation communication training on conflict in patient care. • It is advised that a reminder be given to staff about responding to parent …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 1
Protocols were appropriately considered in transporting Yusuf to Rotherham Hospital, but there were difficult conversations between Yorkshire Ambulance Service staff and the distressed parents as they sought help from the paramedics for their son who was unwell. This added a slight delay to the transfer. • All clinical teams are …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 2
The assessments in primary care could have been more comprehensive (although there was no evidence this impacted the outcome). a. All primary care clinicians who are assessing sick children should have training specific to that assessment, for example, Spotting the Sick Child b. When assessing sick children, clinicians should be …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 4
The Specialist Drug and Alcohol services have put in place a number of initiatives relating to the availability and quality of psychological interventions. The Trust should put in place mechanisms, including regular audit, to assure itself and its commissioners that: • all relevant staff receive appropriate training to deliver these …
south_west
Independent investigation: Terrance Hall, Weston Super Mare (2008) — Rec 3
Given the initiatives and service improvements that have been put in place in the Specialist Drug and Alcohol Services the Trust should put in place mechanisms to assure itself and its commissioners that: • all relevant staff undergo appropriate training which is updated on a regular basis; • staff receive …
south_west
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: Stuart Robertson, Glasgow (2004) — Rec 11.1.4
The Health Board must improve the training of Community Psychiatric Nurses to ensure that they have the required competencies to carry out their functions in relation to conditionally discharged patients. It must also ensure that these nurses are supervised by senior practitioners who take a proactive approach to case scrutiny …
scotland
Independent investigation: Stefan Welch, Brighton (2010) — Rec 2
The Trust will audit its revised CPA processes within six months of the publication of this report. This audit will be devised in conjunction with the relevant Clinical Commissioning Group. Particular focus on the following is required: adherence to CPA policy assessment criteria when allocating service users to CPA …
south_east
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.8
The EIP Service should consider and produce guidance for staff as to the use of the ‘hot spot’ facility in order to maximise its benefit.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Attention should be given to identifying and meeting more thoroughly the training needs of existing, as well as new Mental Health Review Tribunal members.
east_of_england
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
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Department of Health should ensure the funding of adequate numbers of training places for Clinical Psychologists.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The relevant Government departments should set a target date by which time all social supervisors of restricted patients will have acquired the competencies in forensic social work set out by CCETSW.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Police Forces nation-wide should commit themselves to adopting the training and policies for dealing with mentally ill people, as currently practised within the Metropolitan Police.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
An externally facilitated multi-disciplinary review should be undertaken of the balance between behavioural and psychodynamic approaches at Easton House and the skills available to develop a greater degree of flexibility.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Royal College of Psychiatrists, the Royal College of Nursing and other relevant professional bodies, should issue guidance to their respective members not to rest content with information about the 'index offence' but to inquire thoroughly into the criminal events.
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 19
That, following production of the new leaflet which it is proposed should be available to the families of victims of homicides, the Trust implements a staff training programme which takes account of the sensitive nature of providing support to bereaved families; and that the voluntary sector be involved in, or …
midlands
Independent investigation: Richard Marden, Towcester (1999) — Rec 16
That the Trust take immediate steps to ensure that all staff are made aware of or are reminded of the policies in place with regard to the management of Serious Untoward incidents, and, if and insofar as necessary, this Independent Inquiry report be used as a vehicle for further training …
midlands
Independent investigation: Richard Marden, Towcester (1999) — Rec 1
That the Health Authority and the Trust should identify an ongoing training programme for GPs and practice nurses to be made more aware not only of the more common mental health problems in the community and their treatment but also of the presentation and needs of people with major psychotic …
midlands
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.7
We were told about the development of joint management/supervision arrangements for members of the CMHT and about ‘professional’ or ‘clinical’ supervision for various disciplines. We did not discuss arrangements for supervision or support for senior medical staff and we suggest that further consideration is given to developing methods of peer …
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.4.a
A programme to be developed which: i. Builds on existing risk assessment/management training by including relevant details from our report. ii. Provides training concerning MAPPA for all agencies, involving key stake holders for MAPPA - police, prison and probation service, and mental health services.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.2.d
Training In conjunction with the responsible authorities for MAPPA, mental health services should devise a programme of multi-disciplinary training for health staff and other agencies. The purpose of this training would include describing the organisation and function of MAPPA and the processes for sharing information between police, probation and health …
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.i
Training The training of police and probation officers to enhance their knowledge of the CPA should be considered.
london
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.15
Police Community Support Officers should be given additional training in how to identify and respond to people with mental disorder.
south_west
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.7
Practitioners in general psychiatry should receive training to raise awareness of forensic issues and risk factors.
south_west
Scottish Fatal Accident Inquiries(59)
Sharman Weir
I recommend: (a)That the Queen Mother's Hospital should identify a lead obstetric consultant to develop a system for the management of patients with pre-eclampsia and eclampsia. This should include protocol development and updating, and appropriate staff training. (b)That the training of all junior medical staff at the Queen Mother's Hospital should include their being taught (1) about the potential seriousness …
Jan 2003
Stephen Park
This is plainly unsatisfactory and I recommend that the police carry out an audit of their training schedules to ensure that every member of staff who serves in or may be called to serve in the custody suite has received the appropriate and up to date training.
Jul 2003
George Jamieson Fairlie
In terms of Section 6(1)(e) 1. Care Homes which offer a dedicated dementia Unit should ensure that trained nursing staff and staff who work as care assistants have training in the treatment of patients with dementia. 2. All nursing and care staff employed in Care Homes should be given a proper induction at the commencement of their employment and unqualified …
Jun 2006
Lynn Herriot
(2) That in terms of Section 6(1)(c) - the reasonable precautions, if any whereby the death and any accident resulting in the death might have been avoided:- (a) If Scotsac had provided Lynn Herriot with detailed and proper instruction in the use of aqua lung equipment and methods of buoyancy control and had ensured that she had carried out “at …
Nov 2008
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
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
Gordon Ewing
This may be a matter which should be considered by the relevant training bodies. Accordingly, I recommend that a copy of this determination be sent to the Royal College of Anaesthetists for any further action which they may deem appropriate.
Apr 2010
Kieran Nichol
I recommend that consideration be given to devising specific guidance directed towards those providing drug misuse treatment within a residential setting such as Castle Craig where it is likely that the process of titration and stabilisation will be rapid. I recommend that all nursing staff recruited in Castle Craig Hospital to care for drug detoxification patients should undergo a learning …
Jun 2010
Christina Fraser
(a) All heavy goods drivers should be required to undergo compulsory training in loading techniques before being allowed to transport loads, which training should also be on a periodic basis. (b) No load should be transported unless its weight has been accurately ascertained. (c) Every employer involved in the transporting of loads should be required to keep a register of …
Jun 2010
Mary MacMillan Smith Forrest
(1)There should be defined rules or guidelines for nurse co-ordinators and compulsory training for them. (2) All staff nurses or charge nurses who are not acting in the role of nurse co-ordinator should be fully aware of the role of co-ordinators. B514/08 Mary Macmillan Smith Forrest (3) Much more training on procedures including risk assessment, observation and documentation should be …
Dec 2005
Thomas Martin Sanderson, Tony Hayton and Peter Hilton
Section 6(1)(e)(v) The Sea Fish Industry Authority should review the training courses run for fishermen in particular in relation to health and safety risk assessments of fishing in particular conditions and the consideration of the effects of adding ballast to their vessels. The review should consider the requirement for compulsory attendance and re-attendance at such courses.
Mar 2012
Ronald William McAllister
That a comprehensive review be undertaken by greater Glasgow Health Board as soon as reasonably practicable of the following; (i) the training of staff involved in the delivery of haemodialysis to patients; (ii) the procedures for documenting and recording the checks conducted on patients during sessions of haemodialysis; and (iii) the auditing of the practice and procedures in place for …
Mar 2013
John Willock
I trust that these two Recommendations will be fully implemented and that the consequential amendments to Process 18 become operational in the near future. (i) Call Handlers and Nurse Advisors within NHS 24 should ask open questions of a caller with a view to forming a “holistic view” of the patient’s overall health and wellbeing; (ii) Nurse Advisors within NHS …
Oct 2013
Lesley Duncan or Cowie
However, in my view it would be sound practice for consultants to satisfy themselves that junior doctors under their leadership are aware of the appropriate levels of responsibility and can be relied on to seek advice appropriately or refer cases for consultant review when needed.
Jul 2014
John Moody
(1) Those operating light goods vehicles are recommended to follow the good practice recommended in publications by Vehicle and Operator Services Agency and its successor the Driver and Vehicle Standards Agency with regard to: a. Daily walk around inspections of vehicles before they are driven b. Servicing of such vehicles regularly in line with manufacturers recommendations c. Adequate maintenance of …
Oct 2014
Robert Dellow
(5) In terms of section 6 (1) (e): the following guidance is issued to those driving HGV vehicles with a curtain sided trailer: First, drivers are reminded that it is their responsibility to ensure that the driving conditions make it is safe to drive, both in respect of their own safety and that of other road users. Second, that the …
Sep 2014
Raymond Hector Davidson
a. Consideration is given to ensuring that all fishing vessels submit annual Risk Assessments to MCA under The Merchant Shipping and Fishing Vessels (Health and Safety at Work) Regulations 1997 b. Consideration is given to revising the Code of Practice for the Safety of Small Fishing Vessels to the effect that:- i. The wearing of lifejackets at all times is …
Nov 2014
Dawn Fiona Byrne McKenzie
1. Staff and carer training needs should be reviewed to ensure that all first time foster carers approved to take children in middle childhood or adolescence should receive Crisis Prevention and Intervention training prior to taking up their first placement. 2. Prospective foster carers when being asked to consider a placement should be given as much information as possible in …
Andrew Logan
(b) that there is a need to take steps to ensure that all staff at the Ambulance Control Centre of Scottish Ambulance Centre are familiar with, and understand the importance of complying with, the protocol in force in respect of procedure when an urgent call will not be dealt with within the required timescale; It seems to me, therefore, that …
Sep 2015
Brian James MacIver
There should be a joint initiative between the UK Government’s Health and Safety Executive and the Scottish Government’s Agriculture, Food and Rural Communities Directorate to provide further educational guidance in health and safety issues to the farming communities.
Nov 2015
Kevin Michael McGurty
I recommend that Police Scotland and NHS Scotland reconsider their policies in this area. There should if possible be a uniform policy across Scotland, but consideration should be given to equipping all custody stations with AEDs and training officers to make as certain as possible that all officers faced with a situation of a sudden collapse are clearly able to …
Dec 2016
Alexander John Robbins
3. That it is therefore of particular importance that quad bikes should only be driven by persons who have received appropriate training to allow the safe driving of the particular make and model of the quad bike that they are going to use; 4. That an employer, in addition to providing adequate training for employees using quad bikes, should assess …
Sep 2017
Duncan John Matheson
a) All small fishing vessel owners, operators and managers, employers of fishermen and skippers and fishermen on small fishing vessels should make themselves aware of the terms of the following and ensure that they are followed: 1. Marine Guidance Note 588(F) (Compulsory Provision and Wearing of Personal Flotation Devices on Fishing Vessels). 2. Marine Guidance Note 570(F) (Fishing Vessels - …
Feb 2020
George Thomas Allison, Sarah Helen Darnely, Gary McCrossan, Duncan Munro
But I agree with senior counsel for the Crown that the industry and the regulatory authorities should take note of Captain Prior’s evidence that: “by working together, the manufacturer and the operators, you can create that bridge so that the operators understand how the auto pilot was designed to be used and the quirks and the pros and cons of …
Oct 2020
Ian Pollock
of the Act, that this employer keep accurate records that its’ employees have the appropriate training in the operation of quad bikes.
Oct 2020
Iain Neil MacNicol
of the Act that: (a) Anyone working on a farm and using a quad bike should undertake a course of driving instruction before being allowed to use a quad bike. (b) Any adaptations which obscure the driver`s full vision should not be attached to a quad bike. (c) All persons driving a quad bike should wear a safety helmet.
Dec 2020
Mark Barry
That the following recommendation is made: 1. That Sodexo should ensure, so far as reasonably practicable, that all staff trained on the “Talk to Me” strategy are aware: (i) of the limited circumstances when a “concern form” should be completed (see finding in fact 20); (ii) that a single member of staff, trained on the “Talk to Me” strategy, can …
Feb 2021
Anthony Masson
The MCA should be asked to review the methods by which it makes fisherman and other relevant stakeholders aware of the relevant safety legislation and guidance and any significant changes and updates to such legislation and guidance. In particular the MCA should be asked to consider how best to ensure that sole fisherman have made been made aware of any …
Jan 2021
Przemyslaw Krawczyk - Duncan MacDougall
The Sheriff, having considered the information presented at the inquiry, makes the following recommendation in terms of 26(1)(b) of the Act: 1. That stability awareness training be made mandatory for masters of fishing vessels of between 7 and 16 metres in length.
Dec 2021
Pjero Kurida
In terms of section s26(1)(b) (recommendations, if any, as to the taking of any other steps, which might realistically prevent other deaths in similar circumstances): Those responsible for operating merchant vessels in UK waters should have in place the necessary training, guidance, procedures and rules to ensure informed and appropriate responses to medical incidents of uncertain severity. These measures should …
Feb 2022
James Kelly MacGregor
a) A review of the training of officers should take place in order to ascertain whether specific and sufficient reference to the Standard Operating Procedure is included. Thereafter, consideration should be given to officers being tested as part of their training, potentially by way of open book examination, in order to ascertain whether they are familiar with referencing the Standard …
Apr 2023
Graham Rattray
It seems to me that where risks are identified those responsible for the daily care of the vulnerable adult must ensure that carers know and understand the identified risks, know and understand agreed strategies to minimise those risks and know and understand what to do in the event that the risks in fact manifest themselves.
Jan 2008
Marion Helen Adam Ramsay, John Rodgers Cowe and Isabella McGregor
Consideration should be given to the introduction of Consultant Geriatricians as raised in the testimony of Doctor Harrington in accordance with the models used elsewhere in the United Kingdom.
Dec 2007
Gordon Turriff
8.4 Instead I recommend that there should be a review by Mintlaw Transport Limited, in consultation with the Health and Safety Executive, as to the method by which any B192/09 PF Peterhead v Gordon Turriff problem which might arise with, say, the cover of such a partially filled trailer might safely be dealt with without resort to entering the trailer. …
Oct 2009
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter. Advice about …
Aug 2011
Jamesina MacKenzie
It is management’s responsibility to remind staff of their primary duty to the residents and to monitor staff’s fulfilment of that duty. What can be said however, and on this I do agree with the Procurator Fiscal, is that there is a role in the Care Inspectorate in considering the level of medical and nursing expertise available to the care …
Jul 2012
Alan David Bussell
I would suggest that any safe system of work is assisted, and encouraged, by the use of visual reminders. It may be of assistance if written warning labels were affixed to the RC console and to the crane boom, to reinforce the practice of isolating the RC console every time the operator approaches the crane.
Feb 2015
Patricia Janette Wishart
All that we can hope for is that any publicity given to this case will encourage farmers and crofters to pay attention to the published advice of the Health and Safety Executive and the National Farmers Union who, I am told, in the week when this inquiry took place launched a campaign to raise awareness of the dangers which exist …
Jul 2016
Stuart John Whitehead
I can identify that tying or footing the ladder would have prevented the accident. I would accordingly recommend these work practices.
Aug 2017
Gerard Gillies
That the court recommends that all creel fishermen: (a) read the Industry Advisory Note on potting safety, published in January 2001 by Seafish, the MCA’s Fishermen’s Safety Guide, published in May 2014, the MAIB Potting Safety Message, published in February 2014, and MGN 571 (F) - Fishing Vessels: Prevention of Man Overboard; (b) review their system of working in light …
Jan 2019
Angus McAskill
(i) That the Scottish Prison Service should review and revise standing orders for prison officers so as to secure that, where a prisoner complains of feeling unwell, with chest pains, sweating, and a sore throat, at a time when no medical or nursing staff able to carry out an electrocardiogram are on duty within the prison, the prison officer in …
Jan 2021
WIlliam Harrison
1. Steps should be taken to highlight to junior medical and nursing staff the need to escalate the assessment of patients who have a National Early Warning Score (“NEWS”) in excess of 7 in terms of the NEWS checklist. 2. Consideration should be given to revising the guidance on significant adverse events to further emphasise the importance of establishing the …
Jan 2021
Chloe Morrison
1. That the operators of any LGV, or heavy goods vehicle (“HGV”), which is fitted with outriggers should take steps to ensure that any driver operating such a vehicle be trained to ensure that outriggers are safely stowed prior to the commencement of any journey. 2. That the operators of any LGV or HGV fitted with outriggers ensure that drivers …
Jan 2025
Thomas Connolly
The Health & Safety Executive and the relevant bodies such as the Construction Industry Training Board (CITB), the Construction Industry Research and Information Association (CIRIA) and the Institute of Civil Engineers should all take steps to ensure that industry guidance and training courses (for both managers and operatives) are updated to include reference to the circumstances of this accident, namely …
Oct 2006
Mhairi Samantha Convy and Laura Catherine Linda Stewart
However, as the evidence in this Inquiry may raise a question about the level of awareness of the DVLA guidance among medical practitioners I believe the best course in the circumstances is to direct the Sheriff Clerk to bring this Determination to the attention of the appropriate medical bodies - the relevant Royal Colleges - for information, consideration and any …
Nov 2014
Claire Lesley Fairbairn
3. In terms of section 6(1)(e) of the said 1976 Act that other facts which are relevant to the circumstances of Claire Lesley Fairbairn’s death are as follows: (i) the desirability of a paramedic forming part of an emergency ambulance crew and (ii) the keeping of accurate patient records by ambulance crew.
Jan 2015
Jason Jackson
9. In terms of section 6(1)(e) of the said Act, that other facts which are relevant to the circumstances of the death of Jason Jackson are that a standardised approach, such as that set down in the SEWS scale or the Glasgow coma scale, be employed to assess the condition of a prisoner who was suspected of taking drugs. 10. …
Jul 2017
James Scott Miller
I recommended that when doctors are advising patients who drive for a living they should decide if they are fit to drive for a living, not on the type of vehicle they drive or type of licence held by the patient. In my view the DVLA should give further consideration to the distinctions currently used ie group entitlement and focus …
Jan 2018
Philip Reid
In terms of sections 26(1)(b) of the 2016 Act (recommendations (if any) as to the taking of any other steps, which might realistically prevent other deaths in similar circumstances): That the Health and Safety Executive ensure that sufficient information is available and communicated effectively so that those involved in construction and demolition works in relation to agricultural premises are aware …
Jun 2021
George Steen Docherty Gibson Bartlett
Section 26(4) of the Act, I make the following recommendations which might realistically prevent other deaths in similar circumstances, namely circumstances in which members of staff on offshore installations require to carry out work or other activities on or in relation to lifeboats, and involving the attachment of pendants, of a similar nature to those used on the Harding Platform …
Apr 2022
Article 2 learning points(32)
— LP 2
We recommend that at HMP Pentonville all temporary staff receive a prison induction before working in the prison for the first time. As well as covering safety and security issues, this induction should provide coverage of the ACCT Foundation training module (which has since been superseded by ‘Introduction to Safer …
HMPPS
Accepted
— LP 5
(a) We recommend that a single system be introduced at HMP Pentonville that records who has received ACCT training and when the training took place. This system should cover both staff in the main prison and those working on the Healthcare unit. It should also cover both temporary and permanent …
HMPPS
— LP 4
Assuming that it’s impractical for non‐permanent clinical staff to attend an ACCT training course as permanent staff members do and long‐term bank and agency nurses could, we recommend that a protocol be developed at HMP Pentonville to ensure that these staff are at least provided with a systematic ACCT briefing. …
HMPPS
Accepted
— LP 3
We recommend that HMP Pentonville’s Healthcare unit keeps a log of temporary staff who have received a prison induction, whether they be booked through NHS Professionals or otherwise. We think it’s important that this log is easily accessible and made visible to help promote ownership for the provision of these …
PPG
Accepted
— LP 5
Methods of translating Formal Policy Documents into accessible and simplified instructions for Prison Officers using skills-based training methods should be developed.
HMPPS
— LP 20
We recommend that, as a matter of course, escort officers at HMP Pentonville are provided with a briefing as to the nature of the circumstances of the prisoner in their charge and what has been learned about that prisoner. This should provide further clarity for the escort officer as to …
The Governor
Accepted
— LP 7
Staff at HMP Birmingham should receive refresher training on the completion of Cell Sharing Risk Assessment reviews following the receipt of new information.
The Governor
Accepted
— LP 4
Managers at HMP Birmingham should remind staff of the factors that can lead to an increased likelihood that a prisoner will harm his cellmate.
The Governor
Accepted
— LP 3
Managers at HMP Birmingham should ensure that all staff involved in the initial assessment of prisoners on reception receive appropriate training.
The Governor
Accepted
— LP 12
We recommend that GEOAmey review the staff training modules on mental health awareness and interpersonal skills in the light of Dr Craissati’s advice in paragraphs 5.42 to 5.46, noting in particular her focus on behaviours likely to be encountered in a prisoner population, and in developing skills in listening, exploring, …
GEOAmey
Accepted
— LP 11
We recommend that training in suicide prevention is undertaken by all staff who come into contact with prisoners and that the training is refreshed on a regular basis with managers having responsibility for ensuring continued understanding and compliance with the areas covered.
HMPPS
Accepted
— LP 23
We recommend that efforts are made to ensure that representatives from Healthcare units across the Prison Estate meet on a regular basis. We feel that the key to making this a reality is ensuring that the agenda for such meetings is clear and agreed as a group. Meetings should then …
HMPPS
Accepted
— LP 22
We recommend that steps are taken at HMP Pentonville to share findings of future internal investigations, whether these investigations are formal or otherwise, with the relevant audience(s). We would encourage the use of face‐to‐face fora for this, rather than simply circulating investigation reports. This approach should help enhance the feeling …
The Governor
Accepted
— LP 21
We recommend that following serious incidents, measures are taken at HMP Pentonville to ensure that support is provided, and information is actively disseminated, beyond the day of the incident itself. Responsibility for how this support is provided and how information is disseminated should be agreed at the post‐incident hot debrief …
The Governor
Accepted
— LP 18
We recommend that at HMP Pentonville recently‐made entries in the ACCT document, including triggers, are checked by a member of staff attending morning briefings so that any pertinent issues are identified and discussed in this forum.
The Governor
Accepted
— LP 15
We recommend the ongoing use of the record‐keeping audit tool being used on HMP Pentonville’s Healthcare unit, whilst ensuring that it continues to make a tangible difference and informs decision‐making, rather than being seen as a paper‐filling exercise. Showing staff exactly how it is making a difference should further encourage …
PPG
Accepted
— LP 13
(a) We recommend that more is done at HMP Pentonville to make it easier for staff conducting ACCT Case Reviews by clarifying for them what they are trying to achieve and how to fill in the form. We suggest this could be achieved by providing accompanying guidelines. Although it’s in …
HMPPS
— LP 10
We recommend that existing mechanisms for ensuring that quality ACCT entries are made at HMP Pentonville be enhanced. This process may involve: making the process easier for staff by OSRR providing guidance notes to accompany the ACCT document. These guidance notes should make explicit what is being looked for and …
HMPPS
Accepted
— LP 8
We recommend that HMP Pentonville’s Healthcare unit takes steps to understand why ACCT triggers are not always given due consideration in prompting Case Conferences and documented discussions among staff. With this understanding, steps should be taken to improve the current situation. We recommend that any steps identified go beyond simply …
PPG
Accepted
— LP 7
We recommend that the views of clinical staff with respect to ACCT are sought when they attend ACCT training at HMP Pentonville. By understanding in what regard ACCT is held, ACCT trainers will be better placed to explore with those attending how shared ownership of ACCT might be best promoted. …
HMPPS
Accepted
— LP 6
We recommend that part of the ACCT training (Foundation and Case Manager) should be modified by the Prison Service to convey an understanding of prisoner non‐communication and how this should be interpreted, particularly when formulating risk assessments.
HMPPS
Accepted
— LP Healthcare 7
An auditable system should be implemented to monitor completion of annual resuscitation training updates for staff within the healthcare team.
Healthcare Provider
— LP 8
HMPPS should ensure that liaison between Article 2 investigators and prisons is improved by ensuring that the member of staff in an establishment appointed to liaise: a) understands the nature of the Article 2 process, and b) is of sufficient seniority to direct staff and resources to facilitate the investigation.
HMPPS
Accepted
— LP 6
As the impact on staff well-being of traumatic incidents may not be immediately apparent, all staff should be actively encouraged by their managers to access staff care services following such incidents.
HMPPS
Accepted
— LP 19
The prison should perform a formal debrief for all staff involved in a serious incident, with the offer of counselling support.
HMP Altcourse
Accepted
— LP 14
We recommend that some impetus be created at HMP Pentonville to ensure that the option of using discipline staff for one‐to‐one supervision is explored (see Chapter 13). Providing clear accountabilities and a timeframe for getting this piece of work done will go some way towards creating this impetus.
The Governor
Accepted
— LP 9
To improve current audit trails, we recommend making it a requirement at HMP Pentonville that all staff print their name on the ACCT On‐going Record rather than relying on initials or signatures to identify who has made each respective entry. We suggest that amendments are made to the prison’s ‘Guide …
The Governor
Accepted
— LP 11
We recommend that GEOAmey puts in place express policy for aftercare for staff involved in a serious incident through immediate informal support from managers, and further recognition over a longer period, as well as access to independent counselling for staff who wish to use it.
GEOAmey
Accepted
— LP 5
We recommend that policy on the sharing of medical information in the prison setting is clarified and a training programme established to ensure staff understand its implications.
HMPPS
Accepted
— LP 6
I recommend that NOMS checks whether provision and deployment of first aid staff and equipment at Ranby are now at an acceptable level.
NOMS
— LP 5
I recommend that the Governor of HMP Ranby is asked: to note the absence of case notes or other evidence of constructive engagement with WA; to consider what practical arrangements are now in place at Ranby to cultivate positive interaction between staff and prisoners and whether more can be done; …
The Governor (HMP Ranby)
— LP P
Training should be given to ACCT Case Managers to develop skills for use whenever prisoners are unwilling to discuss the trigger points or circumstances surrounding their self-harming.
HMPPS
Partially Accepted
Detention investigations(70)
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R31
Serco managers should undertake a thorough review of the initial training course and the refresher training programme to ensure that they enable staff to fulfil their roles and responsibilities. The review and any consequent redesign of staff training should ensure that staff are adequately trained in mental health matters affecting …
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
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R14
Managers at Gatwick IRCs should undertake a full review of the training needs of existing staff, including needs identified in individual EDRs, and should ensure that the annual refresher training programme and specialist further training meet those needs. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R13
G4S and the SMT should ensure that all staff receive annual refresher training in a timely way. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R9
The SMT and G4S managers should undertake regular and systematic evaluation and quality assurance of the training provided at Gatwick IRCs to ensure that staff receive training of a consistently high standard; that it meets the operational needs of the IRCs, trains and develops staff appropriately and promotes appropriate values. …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R8
The SMT must ensure that all trainers are appropriately trained in the subject on which they deliver training and in how to deliver training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R2
The SMT must ensure that DCMs are given adequate training to fulfil the tasks and responsibilities of their role. (To be completed as a matter of urgency)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 29
I recommend that all caseworkers involved in detention decisions should visit an IRC either on secondment or as part of their mandatory training.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 56
Finally, a comprehensive training package be drawn up for new contract monitors. This should include a period shadowing another contract monitor.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 33
I recommend that further training be provided to escort staff on effective and appropriate engagement with detainees.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R32
Serco managers should consider with the Home Office the possibility of providing training to give DCOs a better understanding of the rudiments of immigration processes.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R7
Managers should review the appraisal process and ensure that those who undertake appraisals have the time, training and support they need to appraise staff in a robust and meaningful way.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R42
G4S Health Services should develop a career pathway for nurses working in Care and Justice. This should be accompanied by the development of customised training materials. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R49
The SMT with the violence reduction manager should undertake a development programme with staff to: • develop their confidence and skills in dealing with disruptive detainees; and • improve their awareness and understanding of the anti-disruption policy and how it should be implemented. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R43
Healthcare and G4S management should ensure that nurses involved in control and restraint understand their role and responsibilities. This should be as part of their induction and refreshed yearly. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R40
The SMT in consultation with the local safeguarding boards must ensure that all staff receive appropriate annual safeguarding refresher training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R38
The SMT must ensure that staff are trained in the management of age dispute cases. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R36
Residential DCMs responsible for ACDT case management should receive regular refresher training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R15
The SMT should ensure that staff dealing regularly with detainees with mental health problems or with drugs or other substance misuse issues receive specialist training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R10
The SMT should undertake unannounced observation of training sessions as part of the evaluation and quality assurance of training. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R3
G4S managers should work with DCMs undertaking training to ensure a common understanding of requirements of that training and how much time DCMs will be given away from operational duties as study leave. (To be completed within 3 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 36
I recommend that IRC staff who have regular contact with detainees should receive mandatory safer detention training on an annual basis.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 26
All relevant Home Offce staff should be trained in making assessments of vulnerability within the parameters of the Adults at Risk policy.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 18
NHS England should continue to roll out staff training on SystmOne/HJIS, and should make sure that patient consent is consistently recorded by conducting a national case fle audit and ensuring that this is a mandatory feld in HJIS.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 57
In my earlier report on Yarl’s Wood, I made a range of recommendations regarding the IMB. These were that the Board: • regularly attends training for DCOs; • undertakes training in race relations and cultural awareness; • draws up a Mission Statement; • introduces instructions for duties which must be …
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 52
I recommend that a module on complaints handling and investigation is incorporated in the training package for contract monitors.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 39
I recommend that Oakington’s IMB members be offered refresher training in relation to their powers and how to ensure maximum effectiveness.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 32
I recommend that staff be trained to ask the detainee by what name he/she would like to be called and to check with him/her their pronunciation of the name.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 15
I recommend that GSL develops a training package for newly promoted managers which should cover amongst other things leadership, giving positive and negative feedback, and effective supervision of staff.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 7
I recommend that GSL reorganises its ITC to ensure that race relations training informs the whole of the course.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R6
Managers should review the centre’s policies, its recruitment, training and appraisal arrangements and the regime at the centre to ensure they are consistent with its mission, role and purpose.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R12
The SMT should consider giving trainees the opportunity to view body camera images of incidents recorded at Brook House. (To be completed within 6 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R11
G4S managers should agree with the Home Office ways that recruits in training can be given early and regular opportunities to experience the environment at times when the detainees are at large in Brook House. (To be completed within 3 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 31
Case progression panel chairs should be of suffcient competence for the role. Attendance from all relevant parts of the Home Offce should be ensured.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 16
A best practice forum should be established across IRC healthcare providers.
Immigration Detention
Review into the Welfare in Detention of Vulnerable Persons — Rec 6
Given my observations at each of the Heathrow terminals and at Cayley House, Tascor should arrange for refresher training for its staff on their duty of care, and the need for proper and meaningful engagement with detainees.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 43
GSL seeks the views of its existing staff to determine what more is required by way of training.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 38
GSL reviews its staff training in respect of handling and defusing confrontation.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 26
in future, all contractors be required to affiliate to the Custodial Care National Training Organisation.
Immigration Detention
Investigation into Allegations of Racism and Mistreatment of Detainees at … — Rec 37
I recommend that IND negotiates with GSL to produce a version of the DVD that could be used for training purposes.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R14
Managers should review staff handover arrangements as a matter of urgency.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R13
Managers should review policy and procedure in relation to entering residents’ rooms and interviews with and checks on residents, particularly at night, to ensure that interviews and checks are as thorough as necessary and carried out in a consistently by all staff.
Immigration Detention
Independent Investigation into Concerns about Yarl's Wood Immigration Removal Centre — Rec R5
Managers at Yarl’s Wood should put in place a programme of organisational development work involving all staff, to develop a clearer and better shared understanding of the centre’s mission, role and purpose, and the cultures and arrangements, including staffing arrangements, that will ensure the appropriate care of Yarl’s Wood’s residents. …
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R35
The residential DCMs should ensure that ACDT case reviews are conducted by DCMs accompanied by a DCO acquainted with the detainee whose case they are assessing. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R50
The SMT must ensure regular and timely review of all use-of-force incidents by appropriately trained staff and that regular meetings take place, involving the SMT, dedicated to considering matters arising from use-of-force incidents and to ensuring that any concerns are addressed. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R5
The SMT should ensure staff have time for debriefing and reflecting about serious incidents in which they have been involved and an opportunity to learn from them. (To be completed as a matter of urgency)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R18
The SMT should ensure that teachers at Brook House, including the arts and crafts teachers, have ready access to the equipment and resources to provide worthwhile programmes for detainees. (To be completed within 3 months)
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R33
G4S and the SMT should consider with the Home Office the possibility of providing the welfare team with training in immigration processes. (To be completed within 6 months)
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 41
The Home Offce should increase the number of its staff who have direct operational experience in closed institutions.
Immigration Detention
Investigation into the Disturbance and Fire at Yarl's Wood Removal … — Rec 50
contract monitors be given training in complaints handling.
Immigration Detention
Independent reviews(50)
Ockenden Review — Rec LAfL 14.17
Improving Complaints Handling All staff involved in preparing complaint responses must receive training in complaints handling.
Health & Social Care
Ockenden Review — Rec LAfL 14.7
Improving Management of Patient Safety Incidents All members of the governance team who lead on incident investigations should attend regular appropriate training courses not less than three yearly. This should be included in local governance policy. These training courses must commence within the next 12 months
Health & Social Care
Neurodivergence Task and Finish Group: report — Rec 4
Recommendation Four: Provide high quality professional development on strengths, needs, and support strategies for neurodivergent children and young people Professional development for the workforce needs to include knowledge and understanding of different forms of neurodivergence, and best practice on how to respond to those differences [10]. Consistent evidence from neurodivergent …
Health & Social Care
Neurodivergence Task and Finish Group: report — Rec 1
Recommendation One: Provide educational professionals with evidence-based valid and accurate holistic educational assessment, along with effective support tools We must separate assessment of educational need from clinical diagnosis. Early Years settings, schools and colleges, should be provided with holistic, accurate educational assessment tools, and their application should be independent from …
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 16
Doctors should receive training in line management and leadership and should be allocated additional time to ensure that they can fulfil their supervisory roles, and to ensure effective running of the health service.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 10
Physician assistants in anaesthesia should have the opportunity for ongoing training and development in the context of a formal certification and credentialling programme, with the ability to take on added responsibilities that are commensurate with that training, including the potential to prescribe and order non-ionising radiation.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 2
Physician assistants should have the opportunity for ongoing training and development in the context of a formal certification and credentialling programme. This should include the ability to take on added responsibilities that are commensurate with that training, including the potential to prescribe and order non-ionising radiation.
Health & Social Care
Building Control Independent Panel — Rec 19
Improve dutyholder understanding of the building regulations and building control by updating the Manual to the Building Regulations and supporting that with a communication drive.
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
Fisher Review (Part 1) — Rec 27
A research study should be undertaken to determine if there are any significant differences in decision making on disclosure between lay magistrates and district judges to determine whether there are any resulting training and development needs for magistrates.
Justice & Legal
Fisher Review (Part 1) — Rec 18
There should be more stringent quality assurance regarding the delivery of disclosure learning by the College of Policing, Higher Education Institutions and other delivery partners. The results of these assessments should be shared with the National Police Chiefs' Council.
Justice & Legal
Fisher Review (Part 1) — Rec 17
Bronze and Silver training and learning standards, referred to earlier, should be reviewed and refreshed by the College of Policing at regular intervals. Law enforcement officers should be expected to undertake 'refresh training' at set intervals.
Justice & Legal
Fisher Review (Part 1) — Rec 16
A Senior Disclosure Officer accreditation pathway, for use across law enforcement agencies, should be established to set consistent standards for officers managing disclosure in complex criminal cases. (Gold)
Justice & Legal
Rejected
Fisher Review (Part 1) — Rec 15
Regarding the further training of law enforcement, the following changes be made: a. A cross-agency disclosure learning standard, for investigators and disclosure officers, should be created. The standard should cover: i. The role of an investigator within the criminal justice system. ii. Their obligations created by the Criminal Procedure and …
Justice & Legal
Accepted
Fisher Review (Part 1) — Rec 14
All major law enforcement agencies should agree a national learning standard, for new officers, regarding content on the operation of the criminal justice system and the importance of disclosure. Each agency should ensure the required content be taught but be given the flexibility to do so within the context of …
Justice & Legal
Accepted
Owens Review — Rec 22
HMPPS review their approach to the balance between centralised and localised design, provision and implementation of training.
Justice & Legal
Owens Review — Rec 21
That a Custodial Managers course is designed, delivered, and made mandatory for all Custodial Managers, and subject to pass/fail assessment before deployment in role. I recognise that staggering of the course may be necessary at initial implementation, but the medium-term objective should be central oversight and sequencing.
Justice & Legal
Hodge Arts Council Review — Rec 12
ACE should leverage its relationships with NPOs and encourage them to strengthen their focus on talent development to ensure good coverage across England. This may include artists in residence opportunities.
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
Pickles Electoral Fraud Review — Rec R5
Guidance and training should be strengthened to ensure that staff in polling stations enforce the rule that voters go to the booth individually.
Other
Williams GNM Review — Rec 8.2
Professional regulators should ensure that fitness to practise panel members have received appropriate equality and diversity training.
Health & Social Care
Williams GNM Review — Rec 5.1
The Royal Colleges, through the Academy, and professional regulators working with appropriate professional bodies should review and, if necessary, amend guidance on how healthcare professionals carry out reflection, stressing the value of reflective practice in supporting continuous professional development. Guidance on carrying out reflection should take a consistent approach across …
Health & Social Care
Williams GNM Review — Rec 4.4
Healthcare providers should ensure that people conducting investigations have received appropriate training, including on equality and diversity. NHS Improvement's SIF should include guidance on how to consider equality and diversity considerations in investigations, including adherence to appropriate equality and diversity standards such as WRES (Workforce Race Equality Standards) standards for …
Health & Social Care
Williams GNM Review — Rec 2.4
Although our terms of reference were limited to gross negligence manslaughter, we heard evidence of more general concerns about experts. This should be reflected in the Academy's work to develop training for healthcare professionals acting in this capacity.
Health & Social Care
Williams GNM Review — Rec 2.3
Professional representative bodies and regulators should recognise acting as an expert witness as part of a healthcare professional's revalidation or continuous professional development (CPD) process.
Health & Social Care
Williams GNM Review — Rec 2.2
Healthcare professionals should be supported and encouraged to provide an expert opinion where it is appropriate for them to do so. Healthcare professional bodies, including Royal Colleges and professional regulators, should encourage professionals to undertake training to become expert witnesses, and employing organisations should be prepared to release staff when …
Health & Social Care
Williams GNM Review — Rec 2.1
The Academy of Royal Medical Colleges, working with professional regulators, healthcare professional bodies and other relevant parties, should lead work to promote and deliver high standards and training for healthcare professionals providing an expert opinion or appearing as expert witnesses. These standards should set out what, in the Academy's opinion, …
Health & Social Care
Carter NHS Productivity Review — Rec 1
NHS Improvement should develop a national people strategy and implementation plan by October 2016 that sets a timetable for simplifying system structures, raising people management capacity, building greater engagement and creates an engaged and inclusive environment for all colleagues by significantly improving leadership capability from "ward to board", so that …
Health & Social Care
Hall-Pesenti AI Review — Rec 8
Universities should encourage the development of advanced credit-bearing AI MOOCs and online Continuing Professional Development courses leading to MScs for people with STEM qualifications to gain more specialist knowledge.
Other
Hall-Pesenti AI Review — Rec 7
Government and universities should create, at a minimum, an additional 200 PhD places dedicated to AI at leading universities. As the UK trains and attracts additional academic talent, this number should grow continually year on year.
Other
Hall-Pesenti AI Review — Rec 6
Universities should explore with employers and students the potential demand for one-year conversion Masters degrees in AI for graduates in subjects other than computing and data science.
Other
Hall-Pesenti AI Review — Rec 5
Industry should sponsor a major programme of students to pursue Masters level courses in AI, with an initial cohort of 300 students.
Other
Jones: Patronising Disposition Review — Rec 16
It has been submitted to me that the medical evidence presented at the fresh inquests may make a useful contribution to the content of additional training for police officers, prison staff and others whose job can involve the restraint of others – in particular in order to reduce the incidence …
Policing & Security
Henley Music Education Review — Rec 33
As part of the National Music Plan, further work should be undertaken to develop a national plan for the use of technology in the delivery of Music Education – and to ensure that the workforce is up-to-date with latest developments. This review should examine how technology could enable better teaching …
Education
Henley Music Education Review — Rec 27
Leadership training among the Music Education workforce is at best patchy. It is recommended that a credible and experienced management training provider be commissioned to provide a nationwide management development scheme targeted specifically at music educators.
Education
Henley Music Education Review — Rec 25
Conservatoires should be recognised as playing a greater part in the development of a performance-led Music Education workforce of the future. All graduates from Conservatoires should study the necessary components within their undergraduate courses to enable them to leave with the Qualified Music Educator award.
Education
Henley Music Education Review — Rec 24
A new qualification should be developed for music educators, which would professionalise and acknowledge their role in and out of school. Primarily delivered through in-post training and continuous professional development, musicians who gain this new qualification would be regarded as Qualified Music Educators. It would be as applicable to peripatetic …
Education
Henley Music Education Review — Rec 21
Much primary school classroom teaching of music is provided by non-specialist teachers. The amount of time dedicated to music in most Initial Teacher Training courses is inadequate to create a workforce that is confident in its own ability to teach the subject in the classroom. It is recommended that a …
Education
Caldicott Review 2013 — Rec 14
Regulatory, professional and educational bodies should ensure that: • information governance, and especially best practice on appropriate sharing, is a core competency of undergraduate training; and • information governance, appropriate sharing, sound record keeping and the importance of data quality are part of continuous professional development and are assessed as …
Health & Social Care
Wachter NHS IT Review — Rec 4
Strengthen and Grow the CCIO Field, Others Trained in Clinical Care and Informatics, and Health IT Professionals More Generally. Given the importance of the workforce to the success of the overall strategy, we recommend an investment in workforce development of £42 million, one percent of the £4.2 billion currently allocated …
Health & Social Care
Wachter NHS IT Review — Rec 3
Develop a workforce of trained clinician-informaticists at the trusts, and give them appropriate resources and authority. We see the absence of professional, well-supported CCIOs with appropriate authority and resources as an enormous obstacle to successful deployment and benefits realisation of health IT at the trust level. Without the availability of …
Health & Social Care
Shelley NHS Hospital Food Review — Rec 1
Catering staff support: a) Develop a national training certificated course for hospital caterers, as part of a public sector training qualification. b) Provide an NHS catering apprenticeship scheme. c) Agree national professional standards with mandatory continuing, career-long professional development, including appropriate compulsory food hygiene and allergen training. d) Improve marketing …
Health & Social Care
Morse Loan Charge Review — Rec 15
review its Charter to set higher expectations of performance during interactions with members of the public, and to ensure that staff are trained to meet these expectations
Other
Francis Curriculum Review — Rec 16
Updates the Key Stage 2 Languages Programme of Study to include a clearly defined minimum core content for French, German and Spanish to standardise expectations about what 'substantial progress in one language' looks like. Should explore the potential benefits of a coordinated approach in their local areas to the main …
Education
Francis Curriculum Review — Rec 15
Adjusts the History Programmes of Study to: improve the understanding and application of disciplinary knowledge and skills through additions and amendments to the disciplinary terms used; clarify the statutory and non-statutory content requirements to better support teachers in recognising and understanding the optionality that exists across Key Stages 1 to …
Education
Francis Curriculum Review — Rec 14
Makes minor refinements to the Geography Programmes of Study and GCSE subject content to respond to the issues identified, including by: refining content to support progression better to further study, deepen children and young people's understanding of key geographical concepts, make content more relevant and inclusive, and remove unnecessary repetition …
Education
Francis Curriculum Review — Rec 13
Updates the Key Stage 3 English Programme of Study to include a discrete section on Drama. This should include more detail to provide greater clarity about expectations for performing, creating and responding to dramatic works. Greater specificity about Drama should be added to the Key Stage 1 and 2 English …
Education
Francis Curriculum Review — Rec 12
Ensures that the English curriculum sets out a clearer purpose, with more clarity and specificity at each key stage, including clarifying the distinction between English and literacy. This should include more clearly drawing out curriculum requirements for speaking and listening, as well as Drama. In particular, more clarity and specificity …
Education
Francis Curriculum Review — Rec 11
Renames the subject 'Food and Nutrition' and ensures it has its own aims and purpose of study that better reflect what it covers and its discrete identity within D&T. Ensures that sufficient detail in the curriculum sets clear expectations about what should be taught at each key stage to reflect …
Education
Francis Curriculum Review — Rec 10
Rewrites the D&T subject aims to be more aspirational, and clarifies the purpose of study to focus on the subject's distinct body of knowledge and capabilities, with a particular focus on Key Stage 3. Refines the D&T curriculum and GCSE subject content to: explicitly include how to achieve sustainable resolutions …
Education
PHSO casework decisions(6)
P-001871 — Manchester University NHS Foundation Trust
Ms G complained the Trust failed to ensure Mr K wore splints, delayed medication, ignored weight loss, provided poor mouth care, and delayed hospital treatment for pneumonia.
NHS in England
Mar 2023
P-002931 — Norfolk and Suffolk NHS Foundation Trust
Ms L complained the Living Well with Autism Course content and staff attitude were inappropriate and discriminatory. She also alleged the Trust mishandled her subsequent complaint and denied reasonable adjustments.
NHS in England
Sep 2024
P-004158 — Gloucestershire Hospitals NHS Foundation Trust
Miss G complained about a lack of nurse escalation, surgical review, and delayed treatment for her father, Mr G, after he deteriorated, leading to his death.
NHS in England
Partly Upheld
Oct 2025
P-001722 — Leeds Teaching Hospitals NHS Trust
Miss I complained Trust staff used excessive force and neglected her late partner, Mr E, between August and September 2021, resulting in physical bruising.
NHS in England
Jan 2023
P-002570 — Great Ormond Street Hospital for Children NHS Foundation …
Mr S complained his son received an inappropriate immunoglobulin dose, wrong treatment, and improper oxygen, contributing to his son's avoidable death.
NHS in England
Apr 2024
P-002542 — James Paget University Hospitals NHS Foundation Trust
Mr A complained about excessive physical restraint used by Trust staff despite his vulnerability and limited mobility, causing bruising, a fractured back, and psychological distress.
NHS in England
Apr 2024
LGO / SPSO decisions(99)
21-015-968 — Birmingham City Council
Summary: Mr X complained the Council failed to properly consider reports he made about an extension his neighbour built. We found the Council did not properly consider the relevance of permitted development rights in this case. However, we found that the outcome was unlikely to have been different. We recommended …
LGO (Local Government & …
Planning
Upheld
Sep 2022
22-005-932 — North Yorkshire County Council
Summary: We will not investigate this complaint about the Council’s Supported Employment Service. The Council has accepted fault, apologised to Mr C and changed his support worker. The Council is monitoring the service and has provided Autism communication training to its staff. It is unlikely that further investigation would lead …
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2022
24-003-010 — Medway Council
Summary: There was fault by the Council in failing to seek confirmation of whether a pupil had previously hit staff on school transport before reaching a decision about the nature of transport required. The Council will apologise, provide a payment to remedy injustice and make service improvements. The complaint is …
LGO (Local Government & …
Education
Upheld
Nov 2024
24-016-542 — London Borough of Bromley
Summary: Mr X complained about the Council’s investigation into the safeguarding and charging services it provided. He says the Council failed to act on the charging issue before it had resolved the safeguarding matter. Also, the Council agreed to cancel the charges but then delayed in doing so. We found …
LGO (Local Government & …
Adult Care Services
Upheld
Jan 2026
25-012-608 — Hertfordshire County Council
Summary: We will not investigate this complaint about the Council’s refusal to investigate Mr X’s concerns. The complaint is late and there are no good reasons for us to exercise discretion to consider it now.
LGO (Local Government & …
Adult Care Services
Jan 2026
25-011-835 — Nottinghamshire County Council
Summary: We will not investigate Mr X’s complaint about how the Council handled a safeguarding investigation. This is because any injustice is not significant enough to warrant our involvement.
LGO (Local Government & …
Adult Care Services
Jan 2026
23-006-082 — Calderdale Metropolitan Borough Council
Summary: Mr and Mrs X complain about the lack of support they experienced from the Council as registered foster carers since 2017. They said it caused them avoidable distress. We found the Council was not at fault in how it supported Mr and Mrs X. However, the Council was at …
LGO (Local Government & …
Children S Care Services
Upheld
May 2024
24-020-695 — Stratford-on-Avon District Council
Summary: We will not investigate this complaint about the conduct of an officer. The Council has acknowledged the Officer’s behaviour fell short of that expected. It has apologised and arranged for further training. We cannot achieve the outcome the complainant is seeking. And we do not consider an investigation will …
LGO (Local Government & …
Planning
May 2025
24-007-592 — Leeds City Council
Summary: Miss X complained that the Council had failed to secure suitable education for her son (Y) and had failed when reviewing his Education Health and Care Plan. She also complained about the lack of adequate training for the Council’s staff. We found fault with the Council’s delay to address …
LGO (Local Government & …
Education
Upheld
May 2025
24-001-796 — London Borough of Bromley
Summary: Ms X complained about the Council’s decision to suspend her child, Y, from school transport. The Council accepts it should not have suspended Y and failed to consult Ms X. The Council has agreed to make a payment to Ms X and train its staff to prevent a recurrence …
LGO (Local Government & …
Education
Upheld
Nov 2024
201102648 — University of the West of Scotland
Mrs C complained on behalf of her son (Mr A) that the university failed to offer guidance and support on his projects during his final honours year. She also complained that the university failed to deal appropriately with her complaint. We upheld Mrs C's complaints, as our investigation found that …
SPSO (Scottish Public Se…
Education
Upheld
Mar 2013
201605940 — Glasgow Caledonian University
Miss C complained that her university failed to provide adequate guidance for her first attempt at her dissertation. She also complained that the university did not allow her to resit two assessments that she had previously passed, even though she had mitigating circumstances. We found that when dealing with her …
SPSO (Scottish Public Se…
Education
Partly Upheld
Jun 2017
201602354 — Lothian NHS Board - Acute Division
Mr C attended A&E at the Royal Infirmary of Edinburgh on two occasions. The first occasion was for constipation and increasing back pain. Mr C's second attendance was due to concern that he may have deep veinous thrombosis (a blood clot in a vein). Mr C complained that when he …
SPSO (Scottish Public Se…
Health
Partly Upheld
Sep 2017
24-015-212 — Avery Homes Kirkstall Limited
Summary: There was an error in the contract presented to Mr X which caused him to believe he would receive a refund of Funded Nursing Care (FNC) payments once paid by the NHS. The care provider has reviewed its staff training and agrees to reimburse the payments to Mr X.
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
201809208 — Lothian NHS Board - Acute Division
C complained on behalf of their late parent (A) regarding nursing and medical care and treatment provided to A during an admission to the Western General Hospital. We took independent advice from a nurse and from a consultant in general medicine and care of the elderly. With regard to the …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2020
201902642 — Lanarkshire NHS Board
C complained about the care and treatment provided to their late parent (A) at University Hospital Monklands. During their admission, there was an incident involving A in the early hours of the morning. The board said that A was mobilised to a commode and, at A's request, given privacy to …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2021
201900708 — Edinburgh College
C, a support and advocacy worker, complained on behalf of their client (A) who was a student at Edinburgh College. A has Autism Spectrum Disorder (ASD, a developmental disability that affects how a person communicates with, and relates to, other people) and dyslexia (a common learning difficulty that can cause …
SPSO (Scottish Public Se…
Education
Upheld
May 2021
23-015-382 — West Northamptonshire Council
Summary: Mrs B complained the Council delayed in completing an Education, Health and Care assessment and failed to meet the statutory timeframe for issuing an Education, Health and Care Plan for her child, X. Mrs B says this caused distress for X and the family. We have found the Council …
LGO (Local Government & …
Education
Upheld
Jul 2024
23-005-990 — London Borough of Croydon
Summary: Mr D says the Council failed to properly investigate his concerns about noise and anti-social behaviour. We have found evidence of fault by the Council and upheld the complaint. We have completed the investigation because the Council agrees to the provide staff training and pay redress to Mr D.
LGO (Local Government & …
Environment And Regulation
Upheld
Jul 2024
24-002-781b — NHS Lincolnshire ICB (24 002 781b)
Summary: Mr X complains about the way the Nursing Home cared for his mother, Mrs Y, and her belongings. We will not investigate this complaint because the organisation has already admitted fault in several areas of Mrs Y’s care. It has apologised, made service improvements, and trained its staff to …
LGO (Local Government & …
Health
Aug 2024
24-002-887 — Royal Borough of Windsor and Maidenhead Council
Summary: X complained the Council failed to take planning enforcement action against their neighbour. We found fault because the Council could not take enforcement action it had intended. This was because it failed to serve papers to a court within time. The Council has agreed to our recommendations and will …
LGO (Local Government & …
Planning
Upheld
Oct 2024
24-004-165 — Royal Borough of Windsor and Maidenhead Council
Summary: X complained the Council failed to take planning enforcement action against their neighbour. We found fault because the Council could not take enforcement action it had intended. This was because it failed to serve papers to a court within time. The Council has agreed to our recommendations and will …
LGO (Local Government & …
Planning
Upheld
Oct 2024
201003865 — Lothian NHS Board
Mrs C entered into an agreement with the board for IVF treatment in accordance with the criteria in place at that time. She waited from December 2008 until 2010 to reach within the top places on the waiting list, however by that time the board’s IVF treatment policy had changed. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2011
201003746 — Education Scotland
Mr C taught at a school which was the subject of an HMIE inspection. Mr C had a number of issues with the outcome of the inspection and this resulted in him raising his concerns in writing with HMIE. His complaint to the Ombudsman stemmed from the way in which …
SPSO (Scottish Public Se…
Education
Partly Upheld
Oct 2011
201104145 — Tayside NHS Board
Mrs C suffered from lung cancer and chronic obstructive pulmonary disease (a disease of the lungs in which the airways become narrowed). She was receiving chemotherapy but after the second cycle her condition deteriorated and she was admitted to hospital, where she died a few days later. Her daughter, Miss …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2012
201202303 — Edinburgh's Telford College
Mr C complained that the college failed to respond to his complaints about the teaching staff on his course. We found that there were a number of shortcomings in the college's handling of Mr C's complaints. It took them too long to respond, not all issues he had raised were …
SPSO (Scottish Public Se…
Education
Partly Upheld
Apr 2013
201104623 — Queen Margaret University
Ms C complained that the university did not follow their regulations in the way they handled her PhD programme. She also complained that when she appealed against being de-registered from the programme, the university failed to respond reasonably to her appeals. The particular issues which Ms C complained about related …
SPSO (Scottish Public Se…
Education
Partly Upheld
Apr 2013
201202324 — Scottish Prison Service
Mr C, who is a prisoner, complained that his personal officer had failed to engage with him appropriately. He was also unhappy with the prison governor's response to his complaint. We were unable to comment on whether the personal officer had encouraged or motivated Mr C in line with the …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Aug 2013
201300592 — Scottish Prison Service
Mr C, who is a prisoner, complained after the prison took the decision to place him under restraint, using a body belt. He said that the decision was unnecessary and that he was held under restraint for more than 12 hours without approval from Scottish Ministers. He also complained that …
SPSO (Scottish Public Se…
Prisons
Partly Upheld
Feb 2014
201406688 — Greater Glasgow and Clyde NHS Board - Acute …
Mrs C complained that when she was admitted to the Western Infirmary with increasing shortness of breath and a productive cough (a cough that produces mucus and phlegm), she was assessed by a clinical nurse specialist (CNS) who said that she could be discharged home that day under the Early …
SPSO (Scottish Public Se…
Health
Not Upheld
Dec 2015
201406068 — Lanarkshire NHS Board
Mrs C complained that her mother (Mrs A) did not receive adequate care during two admissions to hospital. Mrs A underwent surgery in Monklands Hospital to repair a fractured hip, before being transferred to Wester Moffat Hospital for rehabilitation. Mrs C complained that her mother had not been provided with …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2015
201601079 — Lanarkshire NHS Board
Mrs C complained that her mother (Mrs A) was left sitting in a chair for nine hours without access to a bed, whilst waiting to be moved to a new ward. Mrs C said that Mrs A had asked to go to bed during this time. The board told us …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2016
201508619 — Lothian NHS Board
Mrs C complained to us about the medical care and treatment provided to her late father (Mr A) at the Western General Hospital before his death. Mr A had previously been diagnosed with rheumatoid arthritis associated interstitial lung disease (a group of disorders characterized by inflammation and scarring of the …
SPSO (Scottish Public Se…
Health
Upheld
Oct 2016
201604519 — City Of Glasgow College
Mr C complained that the college unreasonably failed to deliver his course in line with the course criteria and that they failed to respond to his subsequent complaint in accordance with their responsibilities. We were satisfied that the college acted in line with the Scottish Qualifications Authority criteria for Mr …
SPSO (Scottish Public Se…
Education
Partly Upheld
Jul 2017
201606182 — Heriot-Watt University
Mr C was removed from his PhD studies following his annual review on the basis of his academic knowledge and performance not being of the required standard to complete his studies. Mr C appealed the decision through the academic appeals process and in supporting his appeal, he complained that the …
SPSO (Scottish Public Se…
Education
Upheld
Jan 2018
201806418 — University of Glasgow
Ms C complained that the university failed to provide her with adequate support after the death of her parent. We found that the university had acted in line with their guidance in relation to this matter. We did not consider that the actions of the university in responding to Ms …
SPSO (Scottish Public Se…
Education
Partly Upheld
Jun 2020
201809975 — Borders NHS Board
C agreed to specialist reconstructive surgery, underwent their treatment, but experienced urinary incontinence thereafter. C said that they had believed the surgery would be of a routine nature and felt that they had not been not provided with adequate information about it; in particular, that a possible side effect was …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2020
201809966 — Fife NHS Board
Mr C complained on behalf of his daughter (Ms A) in relation to charges for treatment provided to Ms A in Victoria Hospital. Ms A was visiting the UK from overseas and attended A&E with palpitations (noticeably rapid, strong or irregular heartbeat). Following assessment in A&E, Ms A was admitted …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2020
201900612 — University of Glasgow
C complained on behalf of their family member (A) who was a disabled student at the University of Glasgow. A had encountered a number of issues which they complained about. As a result of one of those complaints, A understood an action plan for the support for their learning was …
SPSO (Scottish Public Se…
Education
Partly Upheld
Nov 2020
201900610 — University of Glasgow
C’s family member (A) was a disabled student at the University of Glasgow. A month before A sat an exam, adjustments were agreed for the conduct of the exam. The exam was for a subject taught by a different school of the university than their core degree subject. When A …
SPSO (Scottish Public Se…
Education
Upheld
Nov 2020
201803596 — The Robert Gordon University
Ms C began her studies and was given a laptop by the university to assist her. The laptop went on to develop a fault and Ms C requested a repair. The university established that she had been given the laptop without having completed the normal procedures for assessing students requirements …
SPSO (Scottish Public Se…
Education
Partly Upheld
Nov 2020
201900021 — University of Glasgow
Ms C, a postgraduate student, complained that she had paid for classes and seminars which had been cancelled due to industrial action. We found that the University had taken appropriate steps to minimise the academic impact of the industrial action by giving students advance notice of the industrial action and …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
201808095 — University of Glasgow
Mr C was required to complete three school placements as part of his secondary teaching course. Mr C complained that the university failed to provide him with appropriate support during his course and that, after he was deemed to have failed, they did not follow their normal procedure. He was …
SPSO (Scottish Public Se…
Education
Partly Upheld
Feb 2021
201902491 — Tayside NHS Board
C, a support and advocacy worker, complained on behalf of their client (A). A is profoundly deaf and British Sign Language (BSL) is their first language, and so A relies upon BSL interpreters when attending medical appointments. A requested a gender specific interpreter for a GP appointment but when they …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2021
201900199 — Tayside NHS Board
C, a support and advocacy worker, complained on behalf of their client (A). A, whose first language is British Sign Language (BSL), was admitted to Perth Royal Infirmary with concerns about their heart and lungs. During their admission, A's spouse (B) had to translate for them, which they found extremely …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2021
201804582 — Grampian NHS Board
C, a patient adviser, complained on behalf of their client (A) in relation to the care and treatment provided to A's child (B) by the board. B was diagnosed with a type of slow growing brain tumour and subsequently underwent a surgical procedure to treat build-up of fluid in the …
SPSO (Scottish Public Se…
Health
Partly Upheld
Mar 2021
201905097 — Glasgow School of Art
C applied for a Collaborative Doctoral Award (CDA) programme. One of the key features of a CDA is the opportunity to work with an industry partner (IP) as well as academic staff. C complained that their supervision had been flawed and that there had been a lack of engagement with …
SPSO (Scottish Public Se…
Education
Partly Upheld
Sep 2021
202008878 — Lothian NHS Board - Acute Division
C raised complaints about the nursing and medical care their parent (A) received whilst in hospital. English was not A's first language and C also raised complaints about the board's communication with A and their family and whether appropriate follow-up care was provided by the board following C's discharge. The …
SPSO (Scottish Public Se…
Health
Partly Upheld
May 2023
202110475 — Lanarkshire NHS Board
C complained on behalf of their deceased grandparent (A) about care and treatment provided by the board during an admission to hospital following a fall and broken hip. C complained that A received poor nursing care, poor rehabilitation support, had not received enough nutrition and fluids, and had developed necrotic …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2023
202403923 — Ayrshire and Arran NHS Board
C complained about the nursing and medical care and treatment provided to their parent (A) when A was in hospital following a hip fracture. A had surgery for the fracture but was diagnosed with a number of illnesses while in hospital and died. We took independent advice from a nursing …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2025
Domestic Homicide Reviews(3029)— showing 50 strongest matches
Tewkesbury — recommendation 17.10.3
HM Courts & Tribunals Service will conduct a review of domestic abuse training for magistrates and staff, and implement any changes or refresher training required by 31st March 2015.
HM Courts & Tribunals Service
HM Courts & Tribunals …
Tewkesbury — recommendation 17.9.6
The Constabulary Training Department to re-enforce the understanding by officers of the definition of Domestic Abuse and to ensure that where an alleged crime is reported, it is appropriately recorded as a crime.
Gloucestershire Constabulary
Gloucestershire Constabulary
Tewkesbury — recommendation 17.7.5
Implement regular refresher training on Domestic Abuse for all front line housing staff.
Gloucester City Council Housing Service
Tewkesbury — recommendation 17.7.2
There should be in depth housing and homelessness expertise available to clients at the point of first contact. This is necessary to extract relevant information from clients, and offer the most appropriate advice for a range of situations. Customer Services Officers have a generalised knowledge of council services and cannot …
Gloucester City Council Housing Service
Tewkesbury — recommendation 17.4.2
Identify key staff to act as “domestic abuse champions,” to become a single point of contact for identifying victims and provide the necessary training to enable them to facilitate the role.
Cheltenham Borough Homes
Tewkesbury — recommendation 17.4.1
Domestic Abuse Awareness training to be arranged for front line staff. This will enable staff to recognise and respond appropriately to victims of domestic abuse.
Cheltenham Borough Homes
Tewkesbury — recommendation 17.1.2
That CAADA reviews the national training given to IDVAs and to domestic abuse support services relating to the Data Protection Act and the Domestic Violence Disclosure Scheme (Clare’s law).
CAADA
Rotherham — recommendation 17.16
The Trust’s training programme for Band 6 and above A&E staff in undertaking DASH risk assessments should be completed.
Rotherham NHS Foundation Trust
Rotherham NHS Foundation Trust
Rotherham — recommendation 17.15
Domestic Abuse training for the Rotherham NHS Foundation Trust should include what to do in the event of negative disclosure and that further information re Domestic Abuse is available to all Trust staff via its website.
Rotherham NHS Foundation Trust
Rotherham NHS Foundation Trust
Rotherham — recommendation 17.14
South Yorkshire Police should review their assessment process and provide further training and/or awareness for staff.
South Yorkshire Police
South Yorkshire Police
Rotherham — recommendation 17.13
Domestic Abuse training for all agencies within the Safer Rotherham Partnership should include what to do in the event of negative disclosure and that further information re Domestic Abuse is available to all staff via its website.
Safer Rotherham Partnership
Rotherham — recommendation 17.9
IMR author training should be provided to all agencies within the Safer Rotherham Partnership and to 3rd sector organisations. The training should include critical analysis as a key component.
Safer Rotherham Partnership
Bury — recommendation 4
To develop a flow chart for practitioner to use detailing the process of challenge and escalation To provide training on professional challenge
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Bury — recommendation 1
Develop guidance for health practitioners on responding to domestic abuse notifications
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Bury — recommendation 1.
There is a need to ensure that GP practices are aware of risk factors relating to DVA and to know what to do if a concern arises. This has been a previous recommendation and an IRIS training plan is already in place, together with training by the CCG link nurses.
North Manchester Clinical Commissioning Group
Bury — recommendation 1.
The level of knowledge and awareness concerning child safety for all police response staff is reemphasised and reinforced
Greater Manchester Police
Greater Manchester Police
Bury — recommendation 1
That Team Bury Community Safety Partnership considers whether its constituent agencies training on assessing risk in domestic abuse cases needs enhancing to ensure all risk factors are identified before setting the final risk level.
Team Bury Community Safety Partnership
Bromley — recommendation 4.4.7
The Bromley Safeguarding Children’s Board (BSCB) should work closely with schools, colleges and youth services to ensure both young people and the professionals working with them are aware of the realities and dynamics of domestic abuse and where support is available.
Bromley Safeguarding Children’s Board | Schools …
Bromley — recommendation 4.4.5
That the local CCG and Public Health Bromley consider implementing the IRIS programme to support GP’s in identifying and responding to domestic abuse.
Bromley Clinical Commissioning Group | Public …
NHS South East London …
Bromley — recommendation 4.4.4
Local agencies must review or introduce core competencies, training plans, and policies and procedures in relation to domestic abuse, and provide these to the Community Safety Partnership (CSP) and local Children and Adult Safeguarding Boards.
Local agencies | Bromley Community Safety …
Bromley — recommendation 4.4.3
All agencies work with the CSP and the Children and Adult Safeguarding Boards to identify a domestic abuse champion within their agency, each department, or each team (according to size) to attend advanced training and take responsibility for disseminating updates, sharing best practice, and maintaining awareness of domestic abuse within …
All agencies | Bromley Community Safety …
Bromley — recommendation 4.4.2
All partnership agencies should provide all staff with domestic abuse training appropriate to their level of responsibility (e.g. all staff should receive basic awareness training, and staff at level 3 or above should receive advanced training to include risk assessment, safeguarding and referral pathways.) Providing this training is the responsibility …
All partnership agencies
Kingston upon Hull — recommendation 22
Within 6 months, the practice will appoint a designated person who is trained in the use of a Domestic Violence Risk Assessment tool such as the DASH.
GP Practice
Kingston upon Hull — recommendation 21
Within 12 months, the practice will provide domestic abuse training for all staff.
GP Practice
Kingston upon Hull — recommendation 19
When parents who require interpreters in formal meetings, also attend core groups, interpreters should also be provided in these meetings unless the parent/s are very clear that they can understand multiple speakers and do not want an interpreter to attend. This needs to be incorporated into training and procedures. By …
Children’s Social Care
Kingston upon Hull — recommendation 18
For there to be awareness raising/ training made available to social workers regarding different Eastern European countries and their cultures and/or access to such expertise to inform assessments and interventions. By September 2018.
Children’s Social Care
Kingston upon Hull — recommendation 17
That training on CSC Assessments should be reviewed to ensure that it emphasises the need to capture parents/carers’ background histories and their own experiences of being parented, to be underpinned by comprehensive genograms. By July 2018
Children’s Social Care
Kingston upon Hull — recommendation 15
Within 3 months of the onset of this enquiry, awareness training will be delivered to key staff in the DSU departments at HRI and CHH. This has been completed
Hull and East Yorkshire Hospital Trust
Kingston upon Hull — recommendation 8
Continue to work towards finding further information and or training around the benefit entitlement for EEA nationals to prevent any future women in similar circumstances falling into arrears/debt.
Preston Road Women’s Centre Umbrella Housing
Kingston upon Hull — recommendation 6
Continue to work towards finding further information and or training around the benefit entitlement for EEA nationals to prevent any future women in similar circumstances falling into arrears/debt.
Preston Road Women’s Centre
Kingston upon Hull — recommendation 5
Further training around what constitutes a vulnerable adult and what is vulnerability.
Humberside Police
Humberside Police
Kingston upon Hull — recommendation 4
Further training around risk assessing Domestic incidents. Officers who attend incidents are still looking at incidents in their single form and not holistically.
Humberside Police
Humberside Police
Kingston upon Hull — recommendation 3
Further training input about the use of F125’s. There is evidence to suggest that officers are still unsure as to when to submit a form.
Humberside Police
Humberside Police
Kingston upon Hull — recommendation 2
In June 2018, training audit to be completed to ensure all DAP Support Service Support Workers have completed substance misuse training.
Hull Domestic Abuse Partnership Support Service
Kingston upon Hull — recommendation 1
By November 2018 training to be delivered to DAP Support Workers to increase awareness of the impact of domestic abuse on victims from BMER communities and to explore cultural norms and expectations.
Hull Domestic Abuse Partnership Support Service
Lambeth — recommendation 4.9.1
The use of DV risk matrix to be reiterated to managers and social workers and DV training to be mandatory for all social workers /managers and included in inductions.
Lambeth Council Children & Young People’s …
London Borough of Lambeth
Lambeth — recommendation 4.8.3
An update for Health Visitors to include: information and signposting about resources for families with no recourse to public funds.
Guy’s & St Thomas’ Hospital
Guy's and St Thomas' …
Lambeth — recommendation 4.8.2
Specifically review the training requirements and competencies of HV4 and the CNN
Guy’s & St Thomas’ Hospital
Guy's and St Thomas' …
Lambeth — recommendation 4.8.1
Domestic violence risk assessment training / update for Health Visitors.
Guy’s & St Thomas’ Hospital
Guy's and St Thomas' …
Lambeth — recommendation 4.7.2
Staff of London Probation Trust should be reminded about where to find advice about dealing with immigration and other foreign national offender issues. Consideration should be given to providing refresher training to middle managers on key immigration case management issues and policy and procedure changes.
London Probation Trust
Probation Service
Lambeth — recommendation 4.7.1
As part of her on going professional development as she trains to be a probation officer OM1 should be given guidance in how and why to select and present material for inclusion in case records.
London Probation Trust
Probation Service
Lambeth — recommendation 4.6.2
Audit the knowledge and understanding of domestic abuse and its implications for practice across the whole service and act on the findings.
Lambeth Children and Young People’s Service
Lambeth — recommendation 4.4
The Community Safety Partnership to review the training available to its member organisations about current policy and guidance in respect of domestic abuse and people subject to immigration controls.
Community Safety Partnership
Portsmouth — recommendation 9
Training to be multi-agency wherever possible to assist in making learning 'system wide'
CSP
Portsmouth — recommendation 4
Audit content and frequency of training provided to individual agencies involved in this case to ensure training includes: • DASH risk assessment training • Homicide Timeline training • Trauma informed responses • Substance misuse and complex needs • Image based sexual abuse awareness • Counter allegations • Professional curiosity • …
Domestic Abuse Strategy Group
Portsmouth — recommendation 3
Using the victim’s story as a case study, Portsmouth’s multi- agency domestic abuse practitioner’s forum to consult with professionals on what needs to be done to change the culture within their own organisations and as coordinated partners in responding to domestic abuse. Particular attention will be given to unconscious/conscious bias …
Domestic Abuse Practitioners Forum
Portsmouth — recommendation 2
Universal health services revisit training and share information to health professionals regarding the importance of routine screening and asking the question of patients whether they are experiencing domestic abuse, as set out in the NICE guidelines.
CSP
Portsmouth — recommendation 13
Review of processes/policies/training in relation to patients requiring support with drug and alcohol misuse to ensure potential safeguarding issues are considered for all GPs surgeries in Portsmouth.
GPs – Surgeries Portsmouth
Portsmouth — recommendation 11
Raise Awareness of the referral process for adults experiencing or at risk of Domestic Abuse. Training has been commissioned to promote Pan Hants guidance referencing raising safeguarding concerns.
Adult Social Care
Portsmouth — recommendation 7
The CSP would like to receive confirmation that the DA Matters training includes the impact of substance misuse in cases of domestic abuse. (see recommendation 8 below)
Hampshire Constabulary
Hampshire and Isle of …
CJINI inspection reports(12)
An inspection of the training and development of operational staff in the Northern Ireland Prison Service
Prisons, Prison Operations and Management
Jun 2009
An inspection of the PSNI Training Strategy
Policing, Police Internal Operations
Mar 2010
Leadership development and wellbeing support within the criminal justice system in NI
Governance, The Criminal Justice System
Feb 2023
Inspection of Forensic Services in Northern Ireland
Forensic Science Northern Ireland, Forensic Services
Feb 2024
An Inspection of Probation Practice in Northern Ireland
Probation Board for Northern Ireland (PBNI), Probation and …
Dec 2020
Community Restorative Justice Ireland – A pre-accreditation inspection
Restorative Justice, Other Agencies and Organisations
May 2014
The management of Life and Indeterminate sentence prisoners in Northern Ireland
Risk Management and public protection arrangements, Prisons…
Feb 2016
Resolve – A pre-accreditation inspection Report
Restorative Justice, Other Agencies and Organisations
Sep 2016
BASE 2: Working to support individuals under threat – An Inspection of the role Base 2 in threat verification
Other Inspections and Reviews, Other Agencies and Organisat…
Mar 2020
Probation Practice in Northern Ireland- A Follow-Up Review of the Inspection Recommendations
Probation Board for Northern Ireland (PBNI), Probation and …
Aug 2024
An Inspection of Airport and Harbour Policing in Northern Ireland
Policing, Policing and the Community, Harbour and Airport P…
Oct 2025
Answering the Call – A follow-up Review
Policing, Police Internal Operations
Sep 2015
DSA service inquiries(23)
Service Inquiry report into the Loss of Watchkeeper (WK043) Unmanned Air Vehicle over Cardigan Bay in West Wales on 24 March 2017
The Service Inquiry report into the loss of Watchkeeper (WK043) unmanned air vehicle over Cardigan Bay in West Wales on 24 March 2017.
Aviation
Apr 2019
Service Inquiry report into the Loss of Watchkeeper (WK042) Unmanned Air Vehicle over Cardigan Bay in West Wales on 3 February 2017
The Service Inquiry report into the loss of Watchkeeper (WK042) unmanned air vehicle over Cardigan Bay in West Wales on 3 February 2017.
Aviation
Apr 2019
Service Inquiry into the death of a soldier from a gunshot wound at Camp Taji, Iraq on 2 January 2017
Service Inquiry into the death of a soldier from a gunshot wound at Camp Taji, Iraq on 2 January 2017.
Weapons & Ordnance
Nov 2019
Service Inquiry into the death of a soldier following an animal attack at Liwonde National Park, Malawi on 5 May 2019
Service Inquiry into the death of a soldier following an animal attack at Liwonde National Park, Malawi on 5 May 2019.
Other
Oct 2020
Service Inquiry report into the death of a soldier during a Jackal accident on Catterick Training Area
The Service Inquiry report into the death of a soldier of the Scottish and Northern Irish Yeomanry during an accident involving a Jackal vehicle on Catterick training area on 29 January 2019.
Land
Jan 2021
Service Inquiry into the fatal accident involving a Scimitar Fighting Vehicle on Salisbury Plain Training Area - 15 October 2021
Service Inquiry into the fatal accident involving a Scimitar Fighting Vehicle on Salisbury Plain Training Area - 15 October 2021.
Land
Nov 2023
Service Inquiry into the death of a soldier from 23 Parachute Engineer Regiment at MOD Woodbridge, July 2022
Service Inquiry report into the death of a soldier from 23 Parachute Engineer Regiment at MOD Woodbridge in July 2022.
Aviation
Feb 2024
Service Inquiry into the death of a service person during an adventurous training expedition to Stubai Glacier, Austria on 11 March 2023
The Service Inquiry report into the death of a service person during an adventurous training expedition to Stubai Glacier, Austria on 11 March 2023.
Land
Mar 2025
Service Inquiry into death of a Royal Marine during an endurance march on Dartmoor Training Area on 28 May 2015
The Service Inquiry report into the death of a Royal Marine while conducting officer training at Commando Training Centre, Royal Marines Lympstone.
Land
Mar 2016
Service Inquiry into the Watchkeeper (WK031) Unmanned Air Vehicle (UAV) accident at West Wales Airport on 16 October 2014
The report of the Service Inquiry following the Watchkeeper (WK031) Unmanned Air Vehicle (UAV) accident at West Wales Airport.
Aviation
Aug 2016
Service Inquiry into death of a serviceman from 5 Rifles in Paderborn, Germany on 18 June 2015
The report of the Service Inquiry following the death of a serviceman during an annual fitness test, near Alanbrooke Barracks, Paderborn, Germany.
Other
Aug 2016
Service Inquiry into the Watchkeeper (WK006) Unmanned Air Vehicle (UAV) accident at Boscombe Down Aerodrome on 2 November 2015
The report of the Service Inquiry following the Watchkeeper (WK006) Unmanned Air Vehicle (UAV) accident at Boscombe Down Aerodrome.
Aviation
Dec 2016
Service Inquiry into an accident involving a Puma HC MK 2 (XW229) in Kabul, Afghanistan on 11 October 2015
Service Inquiry into the Puma HC Mk2 accident at Headquarters Resolute Support, Kabul, in which five people died when the aircraft struck a tethered surveillance balloon cable on approach.
Aviation
Dec 2016
Service Inquiry into the death of a soldier whilst parachuting at Bad Lippspringe, Germany, on 29 September 2015
The Service Inquiry report into the death of a soldier during an Adventurous Training expedition to Rhine Army Parachute Association (RAPA) in Bad Lippspringe, Germany.
Aviation
Apr 2017
Service Inquiry into the aircraft accident involving YAK52 G-YAKB on 8 July 2016
The report of the Service Inquiry following the YAK52 G-YAKB aircraft accident close to Boscombe Down, Wiltshire
Aviation
Jun 2017
Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013
The releasable extracts of the Service Inquiry report into the deaths of 3 soldiers in the Brecon Beacons, Wales, in July 2013.
Land
Apr 2017
Service Inquiry into the death of a soldier participating in live fire tactical training at Heely Dodd Range, Otterburn on 22 August 2016
The report of the Service Inquiry following the death of a soldier participating in live fire tactical training at Heely Dodd Range, Otterburn on 22 August 2016.
Other
Nov 2017
Service Inquiry report into the Challenger 2 incident at Castlemartin Ranges, Pembrokeshire on 14 June 2017
The Service Inquiry report into the Challenger 2 incident at Castlemartin Ranges, Pembrokeshire on 14 June 2017.
Other
Jul 2018
Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area on 1 November 2016.
The Service Inquiry report into the death of a soldier participating in a Night Live Firing Sniper Cadre at RAF Tain Range Field Firing Area on 1 November 2016.
Weapons & Ordnance
Aug 2018
The Non-Statutory Inquiry (NSI) report into a RAF BLSA Luge accident at Igls Austria on 29 January 2018
A Non-Statutory Inquiry (NSI) has been carried out into a RAF BLSA Luge accident at Igls Austria on 29 January 2018.
Aviation
Sep 2018
Service Inquiry report into the death of a soldier during an annual fitness test at Brecon on 19 July 2016
The Service Inquiry report into the death of a soldier during an annual fitness test at Brecon on 19 July 2016.
Land
Nov 2017
Service Inquiry into the accident involving Red Arrows Hawk T Mk1 XX179 near Bournemouth
Service Inquiry into the death of Red Arrows pilot Flight Lieutenant Jon Egging, whose Hawk T1 crashed near Bournemouth following a display.
Aviation
Dec 2012
Service Inquiry into the accident involving Hawk T Mk1 XX177 at RAF Scampton
Service Inquiry into the death of Red Arrows pilot Flight Lieutenant Sean Cunningham, who was fatally injured when his ejection seat initiated while the Hawk T1 was stationary at RAF Scampton and the main parachute did not deploy.
Aviation
Feb 2014
ISC reports(3)
Women in the UK Intelligence Community
Review of the representation and progression of women across the UK intelligence community.
Special Report
Mar 2015
Diversity and Inclusion in the UK Intelligence Community
Review of diversity and inclusion across the UK intelligence community.
Special Report
Jul 2018
Detainee Mistreatment and Rendition: Current Issues
Companion report examining current policy and guidance on detainee mistreatment and rendition.
Special Report
Jun 2018
CQC enforcement actions(10)
Warning Notice: Greater Manchester Mental Health NHS Foundation Trust
CQC issued Greater Manchester Mental Health NHS Foundation Trust with a warning notice following an unannounced focused inspection in November at Woodlands Hospital. Inspectors found staff had not completed mandatory training, risk assessments and care plans were not appropriately completed, …
Woodlands Hospital
Feb 2023
Urgent Enforcement Action: Bedfordshire Hospitals NHS Foundation Trust
In September, CQC placed conditions on their registration requiring them to outline how they were going to make rapid improvements to risk management, how they were effectively governing the service, and ensuring staff completed the necessary mandatory training required to …
Bedford Hospital and Luton and Dunstable Hospital
Sep 2025
Warning Notice: Croydon Health Services NHS Trust
CQC served the trust a warning notice due to concerns about triage, staff training and appraisal, risk assessments and record keeping, equipment and environment checks, and leadership and governance. Staff didn’t always complete risk assessments and records to the required …
Croydon University Hospital
Nov 2025
Warning Notice: Plymouth Hospitals NHS Trust
Following a visit to Derriford Hospital, the Care Quality Commission found that important check-lists recommended by the World Health Organisation and the National Patient Safety Agency were not being used effectively by surgical teams. The CQC required Plymouth Hospitals NHS …
Derriford Hospital
Feb 2011
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission issued three formal warnings to Medway NHS Foundation Trust following an unannounced inspection of its maternity and midwifery services at Medway Maritime Hospital in August. The inspection found that the trust did not meet national regulations …
Medway Maritime Hospital
Oct 2013
Warning Notice: Barnet, Enfield and Haringey Mental Health NHS Trust
The Care Quality Commission has formally warned Barnet, Enfield and Haringey Mental Health NHS Trust that it needs to improve the care it provides to people using its mental health community services. CQC told the trust to make urgent improvements …
May 2014
Warning Notice: South Central Ambulance NHS Foundation Trust
The Care Quality Commission (CQC) told South Central Ambulance NHS Foundation Trust to make improvements to its safeguarding processes following an unannounced focused inspection in November. Inspectors found that the trust's safeguarding policies were ambiguous, training was limited, and systems …
Feb 2022
Warning Notice: East of England Ambulance Service NHS Trust
Section 29A warning notice concerning the trust's Emergency Operations Centres: mandatory training not kept up to date, call waiting times below national standards, insufficient staffing and cultural concerns across the three sites.
Jan 2025
Warning Notice: Kettering General Hospital NHS Foundation Trust
The Care Quality Commission (CQC) told Kettering General Hospital NHS Foundation Trust it must make urgent improvements to comply with national standards of quality and safety. This followed an unannounced inspection in March 2013 which found that standards relating to …
Kettering, Northamptonshire
May 2013
Warning Notice: Barts Health NHS Trust
The Care Quality Commission issued three formal warning notices to Barts Health NHS Trust following unannounced inspections at Whipps Cross University Hospital in May and June. The warnings required urgent improvements to protect patients and addressed the hospital's non-compliance with …
Whipps Cross University Hospital
Aug 2013
EHRC compliance actions(4)
Section 23 Agreement: McDonald's Restaurants Limited
Section 23 agreement on the handling of sexual harassment complaints by UK restaurant staff, committing to zero tolerance communication, an anonymous worker survey and enhanced training. After hundreds of further complaints the EHRC strengthened the agreement in January 2025.
Feb 2023
Section 23 Agreement: National Highways
Section 23 agreement to improve protection from sexual harassment for around 5,000 employees, after an employment tribunal awarded a former employee £74,000 for sexual harassment and unfair dismissal. Measures included mandatory training and harassment risk assessments.
Nov 2020
National Highways
Section 23 Agreement: Department for Work and Pensions
Section 23 agreement on equality and diversity training entered after a former employee won an employment tribunal claim of direct age and race discrimination, racial harassment and victimisation, with an award of over £386,000.
Department for Work and Pensions
Legal Action / Intervention: Home Office
Intervention in BF v Secretary of State for the Home Department concerning visual age assessment of young asylum seekers, where the Court of Appeal ruled the guidance unlawful for failing to make officials aware of the margin of error. The …
Home Office