Unclear healthcare delegation
Weak and unclear guidance on the delegation of healthcare responsibilities within schools, leading to insufficient clarity.
Source spread
Where this theme appears
This theme appears across 15 independent accountability sources, so the source mix matters as much as the headline total.
7 inquiry recs
21 PFD reports
12 committee recs
6 HSSIB recs
7 CQC actions
2 IMB recs
1 patient safety alert
2 Scottish FAIs
12 DHR recs
5 PHSO decisions
8 LGO/SPSO decisions
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(7)
67 — Defining the personal officer role
Recommendation: The role of the personal officer should be clearly defined in each establishment’s personal officer scheme. The Prison Service should publish a model scheme, which should be regarded as having been adopted by every establishment which does not produce one …
Unknown
54 — Role of duty manager in reviews
Recommendation: The role of the duty manager or duty governor in the review process should be clarified.
Unknown
IHRD-20 — Consultant-Led Ward Rounds
Recommendation: Children's ward rounds should be led by a consultant and occur every morning and evening.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-15 — Consultant Notification on Admission
Recommendation: A consultant fixed with responsibility for a child patient upon an unscheduled admission should be informed promptly of that responsibility and kept informed of the patient's condition, to ensure senior clinical involvement and leadership.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-12 — Senior Paediatric Responsibility
Recommendation: Senior paediatric medical staff should hold overall patient responsibility in children's wards accommodating both medical and surgical patients.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-21 — Nurse Attendance at Clinical Interactions
Recommendation: The accountable nurse should, insofar as is possible, attend at every interaction between a doctor and child patient.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-19 — Senior Lead Nurse in Children's Wards
Recommendation: To ensure continuity, all children's wards should have an identifiable senior lead nurse with authority to whom all other nurses report. The lead nurse should understand the care plan relating to each patient, be visible to both patients and staff …
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
Prevention of Future Deaths reports(21)
Violet Cloudsdale
Concerns: 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.
Overdue
Marjorie Nesbitt
Concerns: 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.
Response (Sheffield City Council): • Sheffield City Council prepared two documents: 'Improving Practice and Reducing Risk' as a case study, and 'Practical Advice' for support workers. • The council stated its intention to share … (AI summary)
Responded
Eleanor Brabant
Concerns: 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.
Overdue
Alexander Davidson
Concerns: 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.
Response (NHS England): • NHS Pathways confirmed call handlers receive communication skills training, including adapting questioning styles and avoiding jargon, supported by monthly call audits. • NHS Pathways reviewed the question regarding 'dark … (AI summary)
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence stated it would reconsider the scope of its pancreatitis guideline (NG104) when it is next reviewed. (AI summary)
Overdue
Stanley Babbs
Concerns: 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.
Response (Barking, Havering and Redbridge University Hospitals NHS Trust): • The Trust implemented a new IV Contrast protocol, communicating it to staff via multiple platforms and providing training on recording radiologist authorisation decisions. • A Practice Group Direction (PGD) … (AI summary)
Responded
Amarbai Bhudia
Concerns: 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.
Response (Barts Health NHS Trust): • The Trust implemented a structured ward round template to improve communication of clinical instructions. • Teaching sessions on nasogastric tube placement were delivered to ward teams, and the Trust's … (AI summary)
Overdue
Samantha Gould
Concerns: 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.
Response (NHS England): • A local protocol has been introduced for CAMHS to advise pharmacies and GPs of relevant care plans for 16-17 year old patients. • This local protocol is now part … (AI summary)
Response (RPS): • The Royal Pharmaceutical Society (RPS) stated it continues to campaign for improved access and sharing of patient health records for community pharmacies. • The RPS has published a policy … (AI summary)
Response (GPC): • The General Pharmaceutical Council stated it would proactively look for opportunities to share the learnings from this case with key stakeholders. • The General Pharmaceutical Council stated it would … (AI summary)
Response (CCA): • The Community Pharmacy Patient Safety Group will discuss the incident to identify learnings and share best practice. • A summary of this discussion will be shared nationally via internal … (AI summary)
Responded
Alison Dallow
Concerns: 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.
Overdue
Harold Wilberforce
Concerns: 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.
Response (General Pharmaceutical Council): • The matter has been referred to a local Inspector for the pharmacy. • The Inspector will assess risks, determine follow-up action, and factor the information into future inspection planning. … (AI summary)
Response (General Pharmaceutical Council): • The specific pharmacy involved updated its Standard Operating Procedures (SOPs) to guide delivery drivers on emergency responses, shared these with staff, and provided relevant training. • The General Pharmaceutical … (AI summary)
Response (Orchard 2000 Pharmacy 1): • The organisation made delivery agents aware of their duty to contact emergency services and inform the pharmacist. • It contacted training providers and reviewed a relevant training programme. • … (AI summary)
Responded
Christian Tuvi
Concerns: 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.
Response (Department for Transport): • The Department for Transport's officials investigated the matter and engaged with the Office of Rail and Road. • London Underground Limited has reached an agreement with its contractors regarding … (AI summary)
Response (Transport for London): • KONE engineers will permanently undertake all inching activities on London Underground moving walks and escalators. • KONE engineers are assessed as competent for inching activities against National Vocational Qualification … (AI summary)
Responded
Katherine Flynn
Concerns: 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.
Response (NHS England): • NHS England proposes that the Society of British Neurological Surgeons (SBNS) co-lead with NHS Nurse Specialists to develop an action plan and national guideline for EVD management. • A … (AI summary)
Response (Society of British Neurological Surgeons): • The Society of British Neurological Surgeons (SBNS) shared the Coroner's summary with its Clinical Leads and members. • The SBNS asked its Clinical Leads to review or develop Standard … (AI summary)
Overdue
Catriona Martin
Concerns: 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.
Response (Aneurin Bevan University Health Board): • The Health Board developed and launched a Person-Centred Enhanced Observational Framework in August 2021, which has been rolled out across all acute and community wards. • Education and training … (AI summary)
Responded
Hannah Jacobs
Concerns: 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.
Response (NHS England): • The shortage of adrenaline auto-injectors has been resolved. • NHS England is reviewing its communications approach for alerting GP practices about medicine shortages. • The Pharmacy and Medicines Optimisation … (AI summary)
Response (BSACI): • BSACI is developing an online allergy education platform for healthcare and non-healthcare professionals, which will cover anaphylaxis recognition and management. • This platform will be rolled out extensively to … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians stated it would work with other professional groups to agree and support standards of care and education related to allergy. • The Royal College … (AI summary)
Response (General Dental Council): • The General Dental Council stated it would write to NICE to highlight that excessive salivation is not listed as a potential symptom of anaphylaxis and request a review of … (AI summary)
Response (General Pharmaceutical Council): • The General Pharmaceutical Council (GPhC) stated its standards require pharmacy professionals to deliver patient-centred care and use professional judgment, including in emergency situations. • The GPhC clarified that registered … (AI summary)
Response (Royal College of Paediatrics): • The Royal College of Paediatrics and Child Health (RCPCH) runs Paediatric Allergy Training study days and includes anaphylaxis management in its training curriculum. • The RCPCH will ensure its … (AI summary)
Responded
Hannah Jacobs
Concerns: The coroner noted a lack of consideration for managing anaphylaxis risk during journeys to and from school. There was no appropriate structure to educate schools, patients, and parents on the importance of carrying adrenaline auto-injectors during these times.
Response (Department of Health and Social Care): • The Medicines & Healthcare products Regulatory Agency (MHRA) launched new guidance in June 2023, reinforcing the importance of carrying two adrenaline auto-injectors (AAIs) and their immediate use. • The … (AI summary)
Overdue
Rachel Gibson
Concerns: 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.
Response (The Royal College of Anaesthetists): • The Royal College of Anaesthetists stated it would disseminate key safety messages regarding local anaesthetic prescription, checking, and administration through its Patient Safety Update publication. • The Royal College … (AI summary)
Responded
David Bennett
Concerns: 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.
Response (Mid South Essex NHS Trust): • The Trust is developing a Shared Care Record and implementing a unified Electronic Patient Record (NOVA) by September 2026, with initial information sharing already underway and staff training planned. … (AI summary)
Response (Essex Partnership University NHS Trust): • The Mental Health Liaison team has been provided with access to all key systems, including SystmOne electronic records. • The Trust is undertaking a review of the Mental Health … (AI summary)
Responded
Pamela Marking
Concerns: 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.
Response (NHS England): • NHS England reported that the Secretary of State for Health and Social Care has established an independent review to consider the identity, naming, and scope of practice for Physician … (AI summary)
Response (Royal College of Emergency Medicine): • The Royal College of Emergency Medicine (RCEM) issued a position statement in June 2024, which included principles for Physician Associates regarding supervision, public awareness, and seeing undifferentiated patients. • … (AI summary)
Response (CQC): • The CQC outlined existing national guidelines and its own guidance that providers are expected to follow regarding Physician Associate integration, scope of practice, supervision, and governance. • The CQC … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care commissioned an independent review into Physician Associates and Anaesthesia Associates in November 2024. • Regulation of Physician Associates and Anaesthesia Associates by … (AI summary)
Response (Association of Anaesthetists RCOA Difficult Airways Society): • The Difficult Airway Society is updating its 2015 guidelines for managing unanticipated difficult intubation in adults, including the section on Rapid Sequence Induction (RSI). • The Association of Anaesthetists' … (AI summary)
Response (GMC): • The GMC has had statutory powers to regulate Physician Associates (PAs) since December 2024, enabling it to set professional standards and conduct registration assessments. • The GMC's public registers … (AI summary)
Response (Surrey and Sussex NHS): • The Trust instructed Physician Associates to introduce themselves to patients by clarifying their role and stating that a senior doctor would oversee care, and installed clear signage in the … (AI summary)
Response (Royal College of Physicians): • The Royal College of Physicians (RCP) submitted findings from a working group on Physician Associates (PAs) to the Leng review, which included a recommendation to change the PA name … (AI summary)
Responded
Hailey Thompson
Concerns: 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.
Response (SSP Health and Ashton Medical Practice): • The practice has reinforced that pharmacists do not prescribe for children and formalised this in a policy. • The requirement for auditable documentation across all clinical communication channels has … (AI summary)
Response (Greater Manchester Integrated Care): • A learning document will be developed to cover responsibilities for safe and effective referrals to treating clinicians. • A reminder on GDPR record-keeping requirements will be shared through the … (AI summary)
Responded
Paul Reeves
Concerns: 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.
Response (The Riverside Group Limited): • The organisation completed mandatory refresher training for staff on medication procedures and implemented a three-month improvement plan to strengthen communication and medication handling. • The national Support Planning Procedure … (AI summary)
Responded
Christopher O’Donnell
Concerns: 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.
Response (Home Group Limited): • Home Group plans a full review of its Support Practice Policy and Tenure Policy, with the updated Support Practice Policy expected by Spring 2026. • Home Group is developing … (AI summary)
Responded
Melanie Pinnell
Concerns: The coroner identified a lack of follow-up from the GP practice for Melanie despite her expressing suicidal ideation, and a prescribed medication request was not actioned by a GP.
Response (Unity Healthcare): • Unity Healthcare is introducing formal caseload reviews between the practice and the Mental Health team. • The organisation is removing the use of the task system for prescribing requests … (AI summary)
Responded
Select committee recommendations(12)
#28 —
Recommendation: 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 …
Response attribution not verified
#27 —
Recommendation: 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 …
Response attribution not verified
#26 —
Recommendation: 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.
Response attribution not verified
#83 — Publish joint statutory guidance on safe delegation of healthcare responsibilities in schools and trusts.
Recommendation: The Department for Education and the Department of Health and Social Care should issue joint statutory guidance clarifying how and when healthcare responsibilities can safely be delegated in schools and multi- academy trusts. This should be produced in collaboration with …
Response attribution not verified
#82 — Guidance on delegating healthcare responsibilities within schools remains weak and unclear.
Recommendation: Guidance on the delegation of healthcare responsibilities within schools and multi-academy trusts remains weak. There is insufficient clarity on how and when healthcare tasks can be appropriately and safely assigned to school or multi-academy trust staff, what training and safeguards …
Response attribution not verified
#17 —
Recommendation: 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, …
Response attribution not verified
#2 — Publish a clear definition of inclusive education with rationale and good practice examples.
Recommendation: 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 …
Response attribution not verified
#1 — Absence of a departmental definition for inclusive education hinders clarity and investment planning.
Recommendation: 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, …
Response attribution not verified
#41 —
Recommendation: The renewed Women’s Health Strategy should include a refreshed national commitment to women’s health hubs across England. We recommend the Government invest at least the same amount as in 2023–25 (£25 million) in ringfenced Integrated Care Board funding for women’s …
Response attribution not verified
#40 —
Recommendation: We are concerned that women’s health hubs have not been specified in the 2025/6 operational planning guidance. There is a high risk that without a central requirement to deliver women’s health hubs, and with Integrated Care Boards (ICBs) required to …
Response attribution not verified
#39 —
Recommendation: 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, …
Response attribution not verified
#38 —
Recommendation: A key success of women’s health hubs is that they have facilitated co- commissioning of long-acting reversible contraception (LARC) by public authority sexual health services and NHS services. This can be an effective workaround for a dysfunctional LARC commissioning system …
Response attribution not verified
HSSIB safety recommendations(6)
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 …
Safety Observation
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
There is variation in the understanding of the role of the critical care outreach team in managing the care and treatment of deteriorating patients.
Area of Improvement
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 …
Safety Observation
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 …
Learning Prompt
Wrong site surgery – wrong tooth extraction
Dental therapists (DTs) – who have a scope of practice that is greater than that of a dental nurse (DN) (see below), but more limited than that of a dentist. For example, a DT may undertake dental examinations and charting, …
Learning Prompt
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.
Area of Improvement
NCEPOD recommendations(1)
CQC inspection actions(7)
Royal Cornwall Hospital
The serviceshouldensurecleardocumentationandguidanceisavailabletostaffregardingmidwifeexemptionandpatientgroupdirectivemedicine.
Should Do
Royal Sussex County Hospital
The trust should ensure that only registered nurses carry medicines keys.
Should Do
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.
Should Do
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.
Must Do
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.
Should Do
Royal Primary Care Chesterfield West
Embed into practice clinical supervision of non-clinical prescribers.
Should Do
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 …
Must Do
IMB individual recommendations(2)
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?
HMPPS
In Progress
Bronzefield (2024)
NHS England specifies the provision of face-to-face GP services, seven days a week. However, to date, this has not been achieved. How and when does NHS England intend to remedy this lack of provision? (6.1)
NHS / Healthcare Provider
National patient safety alerts(1)
Health investigations(96)
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xvi)
The Trust should devise and operate a system whereby the prescription of all medication for service users is undertaken solely by psychiatrists unless General Practitioner treatment is in accordance with agreed shared care protocols.
london
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 5
The Trust should ensure that the MDT review encourages collaborative decision making whilst maintaining clear lines of accountability and responsibility for both the overall care and treatment plan and the individual elements of it.
north_west
Independent investigation report into the care and treatment of Yusuf — Rec 1
Yusuf’s mother was expecting to see a GP and not a primary care nurse practitioner when she made an appointment for Yusuf. Patients who make appointments with their GP surgery should be told which healthcare professional they (or their family member) will be seeing, including their name and position.
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Simon Breed, Wood Green (2004) — Rec R18
Where the patient is receiving inpatient treatment, and prior to referral to the START team and allocation of a care coordinator, the CPA responsibility of the named (or primary) nurse must be clarified.
london
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 5
There should be a clear system for identifying an individual who carries responsibility for the care of each patient at each stage of involvement with the mental health services.
north_east_yorkshire
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 40
The Royal Colleges should provide guidance as to the circumstances (if any) when GPs should maintain sole care of a patient with severe and enduring mental health needs, including the prescribing, administering and monitoring of psychiatric medication, without any secondary care involvement.
london
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 30
There needs to be clarification as to the point at which the consultant assumes clinical responsibility for a patient referred to the CMHT.
london
Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006) — Rec 4
There should be greater inter-agency role clarity. In particular the specific role of outside agencies should be clarified and documented within a patient’s records so that there is a clear understanding between a clinical team and outside agencies as to the role each has to play.
north_east_yorkshire
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 23
The role of the Trust grade psychiatrist in the care team should be defined.
north_west
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 22
When more than one member of a family is involved with services, the role of the care coordinators should be clarified and agreed.
north_west
Independent investigation: Waveney Mclure, Hoxton (2008) — Rec R1
The trust should produce a short document that sets out the key functions of a clinical lead. It should include guidance that will enable clinical leads from any service to be clear about their key responsibilities.
london
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 42
We recommend that the Trust should consider retraining for all staff who may be faced with responding to an AWOL situation. In addition, the AWOL policy should be quite clear that the nurse in charge should take the lead when such circumstances arise.
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 35
We recommend that the AWOL policy should be clear that the Nurse-in-charge at the time of an AWOL ‘event’ is responsible for arranging the immediate actions under the policy (organising a search, informing the senior nurse, (whether on-site or on-call) SHO, next of kin/carers, assessing risk and informing the PSNI. …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 33
We recommend that the Trust’s AWOL policy should provide greater clarity about staff’s responsibilities when voluntary patients are AWOL, including the need to alert the Consultant and senior management at an earlier stage than was done in this case. This is particularly important where risk factors have been identified regarding …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 24
We recommend that decisions on patients being allowed to leave the Unit (e.g. ground pass, hourly pass, day pass etc.) should be covered by the Leave Policy. In this context, clear responsibilities should be established regarding decision-making for these ‘passes’ and the policy should stipulate that decisions are recorded on …
northern_ireland
Independent investigation: Sharon Moore, Lisburn (2003) — Rec 16
We recommend that relevant policies, particularly those pertaining to the delivery of care from the point of admission to the point of discharge, explicitly detail the Primary Nurse role. The duties and responsibilities of the role should be defined, as should the process as to how staff are allocated to …
northern_ireland
Independent investigation: Richard Baker (Mr G), Hastings (2003) — Rec Six
The Trust Board need to satisfy themselves that all doctors in consultant positions are aware of and have clear lines of clinical and managerial responsibility and accountability.
south_east
Independent investigation: Peter Greenfield (PG), Croydon (2003) — Rec 7
The role of the care co-ordinator must be clearly understood by all members of the team allocated this role. (AA)
london
Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green — Rec R10
Haringey tPCT should continue to work with GP1 to specify the role, responsibilities, objectives and key tasks of the primary mental health worker in his practice. This should ensure that maximum benefit is obtained from the investment to improve the service in the practice for people with mental health problems.
london
Independent investigation: Marie Harding, Worthing (2004) — Rec R4
We recommend that the trust clarify whether a referring consultant keeps responsibility until the referred-to consultant sees and assesses a service-user, or whether the responsibility transfers on the date of referral. The point when transfer of responsibility between consultants happens could have far-reaching consequences if a vacuum exists and neither …
south_east
Independent investigation: Lee Johnson, Newcastle (2003) — Rec 7
In matters concerning the operation of a multi disciplinary team there must be a clear understanding between the members of the team as to priorities and the time scale in which any individual tasks are to be completed.
north_east_yorkshire
Independent investigation: Lee Johnson, Newcastle (2003) — Rec 2
A policy framework should be in place so as to allow for those professionals involved to be clear about their roles, the expectations of other team members and to facilitate communication within the multi disciplinary team.
north_east_yorkshire
Independent investigation: Lee Johnson, Newcastle (2003) — Rec 1
The care co-ordinator of a forensic patient within the community (ie currently receiving treatment/service from the Forensic Service), should not be the consultant forensic psychiatrist.
north_east_yorkshire
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R21
The trust should clarify the role of the home treatment team.
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R20
Clinical and management decisions made by the SELT should be contributed to and endorsed by the relevant consultant.
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R10
Each consultant should review only their own patients during their ward rounds (unless covering the leave of another consultant).
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R2
Consultant psychiatrist B’s specialist registrar should not make decisions on behalf of consultant psychiatrist A.
london
Independent investigation: John Curran, Highbury & Islington (2006) — Rec R1
The current model of working between the consultants and specialist registrars should be further examined by the trust to ensure that there is an explicit, single line of consultant responsibility throughout a patient’s inpatient stay and that responsibility is retained as an outpatient, with the SELT team and at subsequent …
london
Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004) — Rec R4
We recommend that the trust clarify whether a referring consultant keeps responsibility until the referred-to consultant sees and assesses a service-user, or whether the responsibility transfers on the date of referral. The point when transfer of responsibility between consultants happens could have far-reaching consequences if a vacuum exists and neither …
london
Independent investigation: Jayne Poppy, Leigh on Sea (2002) — Rec 6
The Trust should ensure that the responsibility for appointing a Care Co-ordinator rests with the cluster leader.
east_of_england
Independent investigation: Janet Keegan, Enfield & Harringay (1997) — Rec 2
The Trust and the Social Services Department should make clear precisely whose responsibility it is to obtain a second medical recommendation for the purposes of converting Section 4 of the Mental Health Act to Section 2.
london
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 19
The delegation of work should follow the appropriate competencies.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 16
Action should be taken to ensure greater clarity of responsibility once an in-patient reverts to care in the community.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 3
That the role and responsibilities of the "named nurse" should be reviewed, including the extent of the responsibility to co-ordinate the services given to the patient.
midlands
Independent investigation: David Kemp, Great Yarmouth (2008) — Rec 1
We recommend that within 3 months of the publication of this report, NHS Lambeth, London Specialised Commissioning Group, and the national DSPD Programme clarify roles and responsibilities for the funding, performance management, oversight and commissioning of this service.
london
Independent investigation: Chloe Fahey, Manchester (2003) — Rec B.1
It is recommended that all social workers in CMHT or social services teams must be reminded that: • They must not advise anyone to change or stop taking medication • They must not request a particular medication for a patient without that patient being seen by a registered medical practitioner.
north_west
Independent investigation: Caroline WillsAshley Wills, Cramlington, North-umberland (2000) — Rec 4
The clear definition of roles and responsibilities (particularly inter-agency relationships) which are regularly evaluated so as to maintain and improve standards and services for users.
north_east_yorkshire
NHS England investigation into an unofficial call-handling project at South … — Rec 7
Commissioners – not providers – should decide what they want provided.
south_east
NHS England follow-up report into an unofficial call-handling project at … — Rec 6
Commissioners not providers should decide what they want provided
south_east
*Independent investigation into the care of Mr A: March 2013 — Rec 5
Prompt consideration should be given to a formal protocol being adopted, governing the roles and responsibilities of the IDTS and MHIRT and the individuals involved. This protocol should take into account the clinical governance and care co-ordination responsibilities of MHIRT and IDTS.
Cambridge and Peterborough NHS Foundation Trust
east_of_england
*Independent investigation into the care and treatment of Patient C: … — Rec 9
When professionals have dual roles, the responsibilities and functions of each is clearly set out and fully discharged.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Accepted
An independent mental health homicide investigation into the care and … — Rec 3
AWP should undertake an urgent review of their CPA and Risk Policies to ensure that they provide clarity regarding recovery navigators’ responsibilities in relation to care coordination and the assessment of risks.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent inquiry into the care and treatment of Ms … — Rec 7
Medical leave to be better co-ordinated and a standardised system of handover of care during these periods to be developed in the CMHT, with consultants making better use of the leave folder in the shared drive.
south_east
An independent inquiry into the care and treatment of Ms … — Rec 4
GPs and mental health professionals need to be explicit about roles, responsibilities and boundaries in patients with complex physical problems and serious mental illness
south_east
Independent investigation into the care and treatment of patient H: … — Rec R2
The medical director should oversee a major review of the function of Ladywood community mental health teams. This must include a clear definition of the role of the consultant psychiatrist and how this role fits with the care of the most complex clients.
Birmingham and Solihull Mental Health NHS Foundation Trust
midlands
Accepted
Independent investigation into the care and treatment of Mr Z — Rec 6
In partnership with LCH, the commissioners of Collette House should clarify the role and nature of the Collette House service provision, including the limits of the service, and clear thresholds for raising and escalation of any concerns.
Mr Z, published on 8 th October 2020. Mr Z was in receipt of services from West London NHS Trust
london
Accepted
*Independent investigation into the care and treatment of Mr A: … — Rec 3
The Independent Investigation Team believes that the allocation of a psychiatrist as a co-ordinator is acceptable in exceptional circumstances. However, these circumstances should be identified in a procedure which includes an element of multidisciplinary working.
Hertfordshire Partnership University NHS Foundation Trust
east_of_england
An independent investigation into the multi-agency care and supervision of … — Rec 1
The service description for the BSMHFT Prison Discharge Service is dated 2016 and requires review because it no longer reflects the remit and work of the service. There is lack of clarity about the scope and remit of the CPNs within the prison discharge service or the role of the …
midlands
Accepted
An independent investigation into the care and treatment of Mr … — Rec 2
The Trust, Local Medical Committee and relevant Clinical Commissioning Groups should develop and agree a shared protocol for the administration of depot medication in the community. This should include agreement as to which party is responsible for undertaking the initial patient assessment, and for the initial and ongoing administration of …
east_of_england
An independent investigation into the care and treatment of a … — Rec 4
The Trust must update the “Operational Guidance, Hull Adult Community Mental Health Teams”, to clarify the role of the Consultant Psychiatrist within the CMHT, and when a medical review of a service user’s care should be sought. The Trust must assure itself that this revised guidance is being followed.
An independent investigation into the care and treatment of a mental health service user Ms C in Humber Teaching NHS Foundation Trust
north_east_yorkshire
Scottish Fatal Accident Inquiries(2)
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 occasions when …
Jun 2006
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
Independent reviews(25)
Independent review of the physician associate and anaesthesia associate roles: … — Rec 15
The General Medical Council requirements for regulation and reaccreditation of physician assistants and physician assistants in anaesthesia in Good medical practice should be presented separately to reinforce and clarify the differences in roles from those of doctors.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 9
Anaesthesia associates should be renamed as ‘physician assistants in anaesthesia’ or PAA and should continue working within the boundaries set in the interim scope of practice published by the Royal College of Anaesthetists.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 7
Standardised measures, including national clothing, lanyards, badges and staff information, should be employed to distinguish physician assistants from doctors.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 6
The physician assistant role should form part of a clear team structure, led by a senior clinician, where all are aware of their roles, responsibilities and accountability. A named doctor should take overall responsibility for each physician assistant as their formal line manager (‘named supervisor’).
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 4
Physician assistants should not see undifferentiated patients except within clearly defined national clinical protocols.
Health & Social Care
Independent review of the physician associate and anaesthesia associate roles: … — Rec 1
The role of physician associate should be renamed as ‘physician assistant’, reflecting the role as a supportive, complementary member of the medical team.
Health & Social Care
Willis Commission on Nursing 2012 — Rec 3
Graduate nurses, as leaders of clinical teams, should supervise and delegate work to 'registered healthcare assistants' with clearly defined roles.
Health & Social Care
Tooke MMC Inquiry — Rec 5
There needs to be a common shared understanding of the roles of all doctors in the contemporary healthcare team that takes due account of public expectations. Given the interdependency of professional constituents of the contemporary multiprofessional healthcare team we suggest a similar analysis extends to other healthcare professional groupings. Clarity …
Health & Social Care
Naylor Review — Rec 12
NHSE and NHSI should provide guidance on the relative roles of providers and STPs with respect of estate matters.
Health & Social Care
Angiolini Review — Rec 29
An unambiguous and high threshold should be set for police involvement in any health care setting. Clear guidance should identify medical primacy of role in any health based setting involving the police.
Policing & Security
Accepted
Angiolini Review — Rec 20
Healthcare professionals should take primary responsibility for the conduct and safe management of restraint of patients in any healthcare setting. This should be part of NHS and police policy. In the absence of support from other agencies the police may have to intervene with some form of restraint, but its …
Policing & Security
Accepted
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 12
Any further expansion in the deployment of physician assistants in anaesthesia should be taken forward in conjunction with the Royal College of Anaesthetists to build safe and effective models of anaesthesia delivery that are supported by the consultant community.
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
Narey-Owers Foster Care Review — Rec 4
We do not believe it is reasonably practicable for carers to be asked to parent a child, while simultaneously preventing them from making minor decisions. We would urge the Department for Education and local authorities to recognise that automatic delegated authority to carers must apply for voluntarily accommodated children too, …
Other
Narey-Owers Foster Care Review — Rec 3
We think that the categorisation of types of decision which might be delegated to carers is sensibly defined in the statutory guidance. But unless carers are explicitly clear about being able, independently, to take decisions, they will continue to feel exasperated. More importantly, children will, unnecessarily, be frustrated, unhappy, and …
Other
Keogh Cosmetic Interventions Review — Rec 5
Non-healthcare practitioners who have achieved the required accredited qualification may perform these procedures under the supervision of an appropriate qualified clinical professional.
Health & Social Care
Wessely Review — Rec 79
The power of associate hospital managers to order discharge following a hearing should be removed.
Health & Social Care
Accepted
Hackitt Review — Rec 2.2
Government should allocate broad responsibilities to Clients, Principal Designers and Principal Contractors responsible for HRRBs as set out in Table 2 – Key responsibilities of dutyholders.
Building Safety
Accepted
Independent review of the physician associate and anaesthesia associate roles: … — Rec 17
DHSC should establish a time-limited working group to set out multidisciplinary models of working in different settings. The group should include input from a small group of experienced leaders covering medicine, other relevant healthcare professionals, management, and human resources.
Health & Social Care
Paterson Inquiry — Rec 3
We recommend that the differences between how the care of patients in the independent sector is organised and the care of patients in the NHS is organised, is explained clearly to patients who choose to be treated privately, or whose treatment is provided in the independent sector but funded by …
Health & Social Care
MacAlister Review — Rec 37
Foster carers should be given delegated authority by default, to take decisions which affect the day to day lives of children in their care.
Education
Hackitt Review — Rec 2.1
Government should specify the key roles that will ensure that the procurement, design and construction process results in HRRBs that are safe. These should be, as a minimum, those identified in Table 1 – Key roles under the CDM Regulations. The definition of these roles should reflect those in the …
Building Safety
Accepted
Ockenden Review — Rec 3
Escalation and accountability. Essential action: Staff must be able to escalate concerns if necessary. There must be clear processes for ensuring that obstetric units are staffed by appropriately trained staff at all times. If not resident there must be clear guidelines for when a consultant obstetrician should attend. • All …
Health & Social Care
Accepted
PHSO casework decisions(5)
P-002638 — East Kent Hospitals University NHS Foundation Trust
Miss R complained the Trust failed to assess her father's swallow and did not isolate him, leading to aspiration pneumonia and COVID-19, which she believes contributed to his death.
NHS in England
Partly Upheld
May 2024
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.
NHS in England
Partly Upheld
Dec 2025
P-002366 — NHS England - South (regional office)
Mrs J complained NHS England wrongly denied her husband CHC funding, alleging the Independent Review Panel's report contained errors and did not follow the National Framework.
NHS in England
Dec 2023
P-002352 — Devon Clinical Commissioning Group
Mrs O complained the CCG gave wrong advice about surgical correction for pectus excavatum, leading to a declined funding application and them paying for the operation privately. This negatively affected Mr R's mental health.
NHS in England
Partly Upheld
Dec 2023
P-002619 — A dental practice in the Essex area
Mrs N complained the Practice incorrectly extracted a tooth without her consent during a procedure, causing severe pain, discomfort, permanent aesthetic changes, and eating difficulties.
NHS in England
May 2024
LGO / SPSO decisions(8)
24-018-678 — City of Bradford Metropolitan District Council
Summary: We have upheld Ms X’s complaint about the Council’s failure to provide adequate information about the costs of adult social care for her father. We asked the Council to remedy the injustice caused. It agreed to apologise and reduce the costs it charges Mr Y. It will also take …
LGO (Local Government & …
Adult Care Services
Upheld
May 2025
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.
LGO (Local Government & …
Health
Jan 2026
22-002-725 — Leeds City Council
Summary: We will not investigate Mrs Y’s complaint about the care provided to her late grandmother, Mrs X. That is because further investigation would not lead to a different outcome, and we cannot achieve the outcome Mrs Y wants.
LGO (Local Government & …
Adult Care Services
Jul 2022
23-020-548a — Creative Support Ltd (23 020 548a)
Summary: Mr A has complained about a care agency and a Council after an investigation by the care agency into a pill found by carers at Ms B’s house. He said the investigation was inadequate and resulted in the care agency withdrawing care to Ms B. We did not investigate …
LGO (Local Government & …
Adult Care Services
Jun 2024
22-005-257 — Banks & Levett Limited
Summary: We will not investigate this complaint about damage to property because it is unlikely we could add to the Care Provider’s investigation or reach a different outcome. The Care Provider has made what appears to be a suitable offer to resolve the matter, the amount in dispute does not …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-001-210 — Thanet District Council
Summary: Mr X complained the Council wrongly refused him a Disabled Facilities Grant for adaptations to his home. He complained its decision was based on a flawed occupational therapy assessment and during a home visit to assess the adaptations, a council officer was rude to him. The Council was not …
LGO (Local Government & …
Adult Care Services
Not Upheld
Sep 2022
22-001-944 — St. Judes Care Ltd
Summary: Mr B complains, on behalf of his father Mr C, that the Care Provider did not properly provide care for Mr C. The Care Provider took too long to reply to Mr B’s complaint and did not follow its complaints process properly. This did not cause Mr C any …
LGO (Local Government & …
Adult Care Services
Not Upheld
Nov 2022
21-018-599 — Chesterfield Borough Council
Summary: We will not investigate this complaint about Miss X’s transfer application and the assignment of her tenancy to her son. There is insufficient evidence of fault which would warrant an investigation. We cannot investigate complaints about tenancy matters concerning social housing landlords.
LGO (Local Government & …
Housing
Apr 2022
Domestic Homicide Reviews(12)
Pembrokeshire — recommendation 23
Welsh Government to clarify expectations relating to the implementation of the National Training Framework and Ask and Act in Primary care services specifically those services which are independently contracted e.g. GP and Dental Practices
Welsh Government
Welsh Government
Sheffield — recommendation 2
Named Accountable GP: Sheffield CCG will request guidance on the role of the Named Accountable GP from NHS England and circulate this.
Sheffield ICB
Northumberland — recommendation 1 (sub-point)
The NSCB will review and revise the early help procedures and guidance to include the following key elements: Agreement that NTW, where appropriate, will take on the role of the Lead Professional.
Northumberland Safeguarding Children Board
Northumberland — recommendation 1 (sub-point)
The NSCB will review and revise the early help procedures and guidance to include the following key elements: The role of the Lead Professional and the contribution and expectations of the Team Around the Family.
Northumberland Safeguarding Children Board
Northumberland — recommendation 4
The Disabled Children’s Team should review the role of the Enquiry and Referral Administrator and duty Social Worker within the team, to include clarity and expectations around the duty Social Worker role in attending Team around the Family meetings and Transitional School Review meetings.
Northumberland County Council (Children’s Social Care …
Stockport — recommendation 2
Pennine Care NHS Foundation Trust : should amend the CPA policy to describe the role of the psychiatrist with regard to the CPA policy and care planning
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Leicester — recommendation 14
It is recommended that any change of regime in the administration of depot medication be discussed and agreed with the responsible Consultant.
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Bedford — recommendation 3.53.
The complex and multi-layered structures within Health can pose barriers to effective communication and clarity of responsibility. All professionals need to take personal responsibility for acting on their concerns for a patient’s wellbeing and safety, be that for a victim of domestic abuse or the safeguarding of children. Staff raising …
Health Agencies
Kent — recommendation 5
CJLDS practitioners should be encouraged to refer disclosures of auditory hallucination to Registered Practitioners or at least consult with them to get the necessary professional advice.
CJLDS (KMPT)
Hammersmith and Fulham — recommendation WLT10
There should be in place the following, understood by all healthcare professionals of the service: o Operational policy for transitions team including referral process o Operational policy for recovery services including assessment of referrals in o Roles and responsibilities re duty function o Clear understanding of zoning. If any professionals …
West London NHS Trust
West London NHS Trust
Ealing — recommendation 7.5.2(b)
Development of lead roles on key areas by particular team members
Ealing Children’s Social Care
Ealing Council
Somerset — recommendation 4
Somerset NHS Foundation Trust should clarify with organisational partners when their ASCC would usually notify a GP when they have conducted an assessment of an individual. This might only be when a person is at risk of harm to themselves or others, but at present there is no clarity about …
Somerset NHS Foundation Trust
Taunton and Somerset NHS …