Unclear healthcare delegation
Weak and unclear guidance on the delegation of healthcare responsibilities within schools, leading to insufficient clarity.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
100match
#82 - Guidance on delegating healthcare responsibilities within schools remains weak and unclear.
Guidance on the delegation of healthcare responsibilities within schools and multi-academy trusts remains weak. There is insufficient clarity on how and when healthcare tasks can be appropriately and safely assigned to school or multi-academy trust staff, what training and safeguards should accompany such delegation, and ultimately where responsibility lies between education and health services. This lack of direction...
Matched on
terms: delegation, healthcare, unclear
Committee recommendation
95match
#83 - Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with school and multi-academy trust leaders and health and education unions and set out clear lines of accountability between...
Matched on
terms: delegation, healthcare
PFD report
77match
David Bennett
The coroner noted gaps in mental health information sharing between services, leading to inaccurate records and insufficient escalation of care. Concerns were also raised about unclear operational policies and the delegation of risk assessment.
Matched on
terms: delegation, unclear
PFD report
61match
Violet Cloudsdale
The coroner identified a lack of risk assessment and documented consent for the use of lap belts on wheelchairs, noting unclear guidance on their use and the potential for them to be considered unlawful restraint.
Matched on
terms: unclear
PFD report
61match
Rachel Gibson
Inadequate recording of oral instructions and insufficient verification by the prescribing anaesthetist created unclear responsibility for checking and administering local anaesthetic. Inconsistent prescription of local anaesthetic (ml vs mg) was also identified as a risk.
Matched on
terms: unclear
PFD report
57match
Alexander Davidson
The NHS 111 service used medical terminology unclear to young patients and rigid scripts. Concerns were also raised about delays in GP uploading of triage notes and the lack of routine lipase/amylase testing for young people with abdominal symptoms.
Matched on
terms: unclear
PFD report
57match
Alison Dallow
The coroner identified unclear clinical advice regarding weight-bearing status and an ambiguous hospital policy for reducing Venous Thromboembolism risk, especially for outpatients with fractures. Additionally, evidence of information provided to the patient was unavailable.
Matched on
terms: unclear
PFD report
57match
Paul Reeves
Concerns were raised about the supported accommodation's unclear role in medication supervision and a significant lack of communication between its staff and the mental health unit regarding changes in a resident's mental state and the escalation of deterioration.
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terms: unclear
PFD report
53match
Harold Wilberforce
The coroner noted a lack of training for pharmacy delivery agents on managing fallen elderly patients at home, and a lack of clarity regarding their roles and responsibilities in such situations.
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PFD report
53match
Katherine Flynn
The Trust's policy lacked clarity on how nursing staff should escalate issues with external ventricular drains that stopped draining but still oscillated. There is no standard national policy addressing this specific risk, leading to variations across Trusts.
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CQC action
52match
Northwick Park Hospital
The trust should work with system partners to ensure there is a seamless service and clarity about clinical decision making in the provision of care at the trust and other NHS providers of mental healthcare.
Matched on
terms: healthcare
CQC action
52match
Ealing Hospital
The trust should work with system partners to ensure there is a seamless service and clarity about clinical decision making in the provision of care at the trust and other NHS providers of mental healthcare.
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terms: healthcare
PFD report
49match
Eleanor Brabant
Insufficient staff training was identified regarding Mental Health Act Section 5(4) powers for informal patients and the duty to safeguard vulnerable crime victims by reporting incidents to police.
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PFD report
49match
Amarbai Bhudia
Instructions for managing the NG tube were not clearly noted by the House Officer, and nursing staff, including agency staff without relevant training, lacked clinical guidance. Concerns about the NG tube's function were also not properly escalated to clinical staff.
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PFD report
49match
Samantha Gould
The coroner raises concerns about the lack of national guidance for pharmacies to be involved in medication safety plans for mental health patients aged 16-17, noting this poses a risk of future fatalities.
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PFD report
49match
Christian Tuvi
The coroner identifies an ongoing impasse between organisations regarding a permanent safe system for communicating conveyor movement and the training of operatives on travellator controls. This involves the lack of agreed standards for competency assessment and insufficient training provision.
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PFD report
49match
Hannah Jacobs
The coroner noted dental staff did not recognise excessive salivation as anaphylaxis, and allergy plans listing lip swelling as mild risked false reassurance. There is a need for clearer guidance differentiating anaphylactic from mild reactions and for enhanced patient education on adrenaline auto-injector use.
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PFD report
49match
Pamela Marking
Concerns include the misleading 'Physician Associate' title, affecting public understanding and informed consent. The coroner also notes an absence of national and local guidelines for Physician Associate scope of practice and direct supervision, potentially impacting patient safety.
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CQC action
48match
We Can Recover CIC
Although the service had contracted a named GP prescriber, their role and cover arrangements remained unclear. The registered manager could not confirm if the named doctor was acting as an independent doctor or prescribing care and treatment under the regulated activity accommodation for persons who require treatment for substance misuse on behalf of or employed by, We Can...
Matched on
terms: unclear
PFD report
45match
Marjorie Nesbitt
The coroner identified that carers lack specific training on how to manage unusual situations, such as adjusting environmental controls like heaters for clients, and recommended including such scenarios in future training.
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PFD report
45match
Stanley Babbs
Contrast media, a prescription-only medicine, is administered without a formal prescription, careful dose consideration, or a clearly identified responsible clinician, particularly for high-risk patients. There are no specific prescribing safeguards for patients with an eGFR lower than 30.
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PFD report
45match
Catriona Martin
The coroner noted the unacceptable level of care expected from Catriona’s mother and a lack of guidelines for delegating nursing duties or for the nursing team's supervision and intervention requirements.
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PFD report
45match
Hailey Thompson
The coroner identified gaps in the GP surgery's call handling process, noting a lack of clear pathways and triage tools for administrative staff to recognise urgent medical needs and ensure appropriate clinical referral, such as for suspected allergic reactions.
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PFD report
45match
Christopher O’Donnell
The supported living provider's policy did not allow staff to remove excess medication for safeguarding a resident experiencing a mental health crisis, as it required the resident's consent.
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Committee recommendation
45match
#28 - 4th Report - Homecare medicines services: an opportunity lost
NHS England should designate a senior, named person with responsibility for the homecare system. That person should be given sufficient powers and resources to discharge that responsibility. Responsibilities should include: (a) Setting clear national KPIs for organisations commissioning and providing homecare medicines services to use. (b) Collecting data on those KPIs, and publishing data on those KPIs in...
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HSSIB recommendation
45match
Surgical care of NHS patients in independent hospitals
It may be beneficial if collaborating NHS and independent hospitals had clearly defined, accessible and usable procedures clarifying the roles, responsibilities and accountabilities of both hospitals when delivering NHS-funded surgical care in an independent hospital. These should be transparent to staff delivering and patients receiving care.
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GIRFT recommendation
45match
Orthopaedic Trauma
Trusts should have written policies identifying the clinical staff involved in the treatment of 'orphan conditions', for which there is no one specialty that considers themselves to be trained to manage patient care. We will also co-develop guidance on collaborative management of orphan conditions with specialty associations and colleagues in national bodies, such as the GMC and elsewhere...
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CQC action
45match
Royal Cornwall Hospital
The serviceshouldensurecleardocumentationandguidanceisavailabletostaffregardingmidwifeexemptionandpatientgroupdirectivemedicine.
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PHSO casework decision
44match
P-004450 - Royal Devon University Healthcare NHS Foundation Trust
Mr B complained the Trust inappropriately changed his planned anaesthetic for catheter insertion, causing trauma, bleeding, and triggering PTSD due to a missed bladder and hit vein.
Matched on
terms: healthcare
Committee recommendation
41match
#27 - 4th Report - Homecare medicines services: an opportunity lost
Chief Pharmacists must have the powers and resources to ensure high quality homecare medicines services in their area. This should include powers and responsibility to develop and support alternative ‘back up’ provision to deliver homecare medicines services, such as through local pharmacies. This would both empower trusts in their market position, and create a more resilient homecare system.
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Committee recommendation
41match
#26 - 4th Report - Homecare medicines services: an opportunity lost
Chief Pharmacists are responsible for homecare services in their area but in most cases they do not have the powers or levers to fulfil that responsibility.
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HSSIB recommendation
41match
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.
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NCEPOD recommendation
41match
Time to Get Control?
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CQC action
41match
Royal Sussex County Hospital
The trust should ensure that only registered nurses carry medicines keys.
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Committee recommendation
40match
#1 - Absence of a departmental definition for inclusive education hinders clarity and investment planning.
We welcome the Department’s focus on inclusive education; however, we are concerned about the absence of a Departmental definition of this and the subsequent lack of clarity about what ‘inclusive mainstream’ education looks like and means in practice for educators, education settings, pupils and families. We are also concerned that the Department does not appear to have a...
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Committee recommendation
36match
#17 - 79th Report - Supporting people with frailty outside hospitals
NHSE told us that it is looking at interventions that could be done by other health care professionals in primary care. For example, enhancing the clinical service community pharmacists provide to include undertaking medication reviews for people with frailty.36 However, we have had written evidence from pharmacists who are keen to do this work but told us that...
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Committee recommendation
36match
#2 - Publish a clear definition of inclusive education with rationale and good practice examples.
It is unacceptable that a clear definition of inclusive education is still lacking. The Department must publish a definition of inclusive education and rationale for this vision alongside examples of good practice across different phases of education and settings within the next 3 months. Continued ambiguity undermines progress and accountability. (Recommendation, Paragraph 35)
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HSSIB recommendation
36match
Placement of nasogastric tubes
It may be beneficial if accreditation for reviewing, recording and communication of the clinical evaluation of the X-ray findings, prior to initiation of feed, is limited to specific staff groups trained in confirming nasogastric tube placement, for example reporting radiographers or radiologists.
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HSSIB recommendation
36match
Wrong site surgery – wrong tooth extraction
Dental hygienists – who carry out treatment which helps patients maintain their oral health by preventing and treating periodontal disease and promoting good oral health practice. Many dental hygienists also have an additional qualification as a dental therapist; this was true of the dental therapist in the reference event.
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HSSIB recommendation
36match
Sepsis: a patient with a urine infection
Variability in the medical support accessed by nursing staff due to the medical care arrangements for the nursing home.
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GIRFT recommendation
36match
Ophthalmology
Increase the capacity and productivity of wet AMD pathways, through more extensive use of virtual clinics for stable patient monitoring and clean rooms for intravitreal injections, while training more members of the non-medical HCP team to carry out injections. Actions: a) Providers to review their wet AMD pathways to identify opportunities to use virtual clinics to reduce the...
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GIRFT recommendation
36match
Cardiology
Arrhythmia pathways should incorporate rapid access clinics, which may be led by ACPs, specialist nurses or cardiac physiologists, for the assessment of palpitations and suspected or confirmed AF. Cardioversions should, by default, be nurse, physiologist or ACP led and undertaken outside the cath lab. a) GIRFT will support NHSE/I regions and networks to audit current level of trust...
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CQC action
36match
North Devon District Hospital
Ensure the management of patients with different needs to the speciality of the ward are safe and ensure appropriate medical oversight.
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CQC action
36match
Royal Primary Care Chesterfield West
Embed into practice clinical supervision of non-clinical prescribers.
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Scottish FAI
36match
Shomi Moshina and Steven Alexander Wiseman
Consideration should however be given to devising a formal system to ensure so far as can reasonably be done that algorithm outcomes are not overridden save for clear and identified reasons; that the ability of nurse advisors to make that decision should be tested before they are allowed to do so, and should thereafter be regularly reviewed. The...
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Scottish FAI
36match
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.
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GIRFT recommendation
36match
Paediatric Critical Care
Develop network clinical pathways, which clearly describe aspects of care that are to be delivered within each spoke hospital, and implement regular monitoring of spoke activity and spoke to hub PICU transfers. a Develop written network pathways of care for at least the following, identifying aspects of care that should be delivered in spoke hospitals (L1, 2), and...
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Committee recommendation
35match
#39 - 12th Report – Menstrual health of girls and young women
We strongly disagree with the Minister’s argument that further ringfenced funding to support NHS Integrated Care Boards to maintain and develop women’s health hubs is unnecessary. The implementation of women’s health hubs is not complete. There are inconsistencies in provision, they do not cover all areas of the country and not all of those that have been established...
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terms: healthcare
IMB recommendation
35match
Wymott (2024)
The Board has been concerned about the triaging of hospital escorts by Duty Governors, as these are clinical decisions (see section 6.2). Can HMPPS offer assurances that negotiations for the new healthcare contract will address this?
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terms: healthcare
LGO / SPSO decision
34match
25-009-869a - Clarity Homecare (Bristol) (25 009 869a)
Summary: Mr A complains about the Avon Healthcare in relation to care provided to Mrs B which he said led to her death. We will not investigate the complaint as we would be unlikely to find fault or add to the work Avon Healthcare has already carried out.
Matched on
terms: healthcare