Unqualified Staff Deployment
Deployment of insufficient numbers of suitably qualified, competent, skilled, and experienced staff, failing to meet fundamental standards.
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.
18 inquiry recs
55 PFD reports
25 committee recs
11 HSSIB recs
79 CQC actions
3 PPO recs
2 IOPC recs
3 IMB recs
1 detention investigation rec
5 DHR recs
3 PHSO decisions
12 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(18)
COVID-M2.3 — UK-wide Expert Register
Recommendation: The Government Office for Science (GO-Science) should develop and maintain a register of experts across the four nations of the UK who would be willing to participate in scientific advisory groups, covering a broad range of potential civil emergencies. The …
Gov response: GO-Science already maintains an expert register for SAGE and is committed to refreshing the register; improving selection processes to broaden participation across disciplines, institutions and backgrounds; and increasing our engagement with experts outside of emergencies. …
Accepted
COVID-M1.5 — Pandemic Data Systems and Research
Recommendation: The UK government, working with the devolved administrations, should establish mechanisms for the timely collection, analysis, secure sharing and use of reliable data for informing emergency responses, in advance of future pandemics. Data systems should be tested in pandemic exercises. …
Gov response: The government agrees with the Inquiry that data and research are crucial to preparing for, responding to and recovering from a pandemic. The government recognises that effective response to any future pandemic requires a refined …
Accepted
COVID-M1.2 — Cabinet Office Leadership for Emergencies
Recommendation: The UK government should: abolish the lead government department model for whole-system civil emergency preparedness and resilience; and require the Cabinet Office to lead on preparing for and building resilience to whole-system civil emergencies across UK government departments, including monitoring …
Gov response: The government agrees with the need for a greater Cabinet Office role for whole-system civil emergencies. This is in addition to the Lead Government Department model which retains an essential role in preparedness and resilience. …
Accepted in part
35 — Contractors' supervisors as Performing Authorities
Recommendation: While it is not inappropriate for contractors’ supervisors to act as Performing Authorities, operators should be made responsible for ensuring that such supervisors are trained in the permit to work system for the installation where they are to act as …
Unknown
33 — Training of contractors' supervisors
Recommendation: Operators and the regulatory body should pay particular attention to the training and competence of contractors’ supervisors who are required to operate the permit to work system (paras 18.17 and 18.29).
Unknown
105 — UKOOA guidelines for emergency training
Recommendation: The UKOOA guidelines for offshore emergency safety training on installations should be a minimum requirement for survival, fire-fighting and other forms of training detailed therein for the relevant personnel employed offshore. Personnel who have not met the requirements of these …
Unknown
BRIS-99 — Mandate direct supervision for clinicians performing new clinical procedures until expert
Recommendation: Any clinician carrying out any clinical procedure for the first time must be directly supervised by colleagues who have the necessary skill, competence and experience until such time as the relevant degree of expertise has been acquired.
Unknown
R23 — TVN training and qualification
Recommendation: Health Boards should ensure that a nurse appointed as Tissue Viability Nurse (TVN) is appropriately trained and possesses, or is working towards, a recognised specialist post-registration qualification. Health Boards should ensure that a trainee TVN is supervised by a qualified …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
IHRD-13 — Foundation Doctors in Children's Wards
Recommendation: Foundation doctors should not be employed in children's wards.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F213 — Training standards for healthcare support workers
Recommendation: Until such time as the Nursing and Midwifery Council is charged with the recommended regulatory responsibilities, the Department of Health should institute a nationwide system to protect patients and care receivers from harm. This system should be supported by fair …
Gov response: Not accepted, however we intend to achieve the intention behind this by ensuring that organisations have the right staff with the right skills to deliver care in a safe way. We do not believe that …
Not accepted
F212 — Training standards for healthcare support workers
Recommendation: The code of conduct, education and training standards and requirements for registration for healthcare support workers should be prepared and maintained by the Nursing and Midwifery Council after due consultation with all relevant stakeholders, including the Department of Health, other …
Gov response: Not accepted, however we intend to achieve the intention behind this by ensuring that organisations have the right staff with the right skills to deliver care in a safe way. This recommendation is a step …
Not accepted
F211 — Training standards for healthcare support workers
Recommendation: There should be a common set of national standards for the education and training of healthcare support workers.
Gov response: Accepted. The National Minimum Training Standards for healthcare support workers were published in March 2013. The Cavendish Review has also made a number of recommendations to improve the national standards on education and training, including …
Accepted
F210 — Code of conduct for healthcare support workers
Recommendation: There should be a national code of conduct for healthcare support workers.
Gov response: Accepted. Skills for Health and Skills for Care published a national code of conduct for healthcare support workers and adult social care workers in March 2013. The Cavendish Review recommends that Skills for Health and …
Accepted
F209 — Registration of healthcare support workers
Recommendation: A registration system should be created under which no unregistered person should be permitted to provide for reward direct physical care to patients currently under the care and treatment of a registered nurse or a registered doctor (or who are …
Gov response: Not accepted, however we intend to achieve the intention behind this by ensuring that organisations have the right staff with the right skills to deliver care in a safe way. The Government understands that the …
Not accepted
F208 — Strengthening identification of healthcare support workers and nurses
Recommendation: Commissioning arrangements should require provider organisations to ensure by means of identity labels and uniforms that a healthcare support worker is easily distinguishable from that of a registered nurse.
Gov response: Accepted in principle. We agree that patients should be clear on the role of people caring for them, for example through identity labels, clear job titles and uniforms. Many organisations already do this. However, the …
Accepted in part
F207 — Strengthening identification of healthcare support workers and nurses
Recommendation: There should be a uniform description of healthcare support workers, with the relationship with currently registered nurses made clear by the title.
Gov response: Accepted in principle. This is a complex issue as healthcare support workers carry out a number of different tasks in varied roles, so a uniform description can be difficult. The Cavendish Review80 recommends that once …
Accepted in part
BRIS-186 — Require all surgeons operating on children to obtain paediatric qualification and revalidation
Recommendation: All surgeons who operate on children, including those who also operate on adults, must undergo training in the care of children and obtain a recognised professional qualification in the care of children. As matter of priority, the GMC, the body …
Unknown
BRIS-184 — Ensure children are cared for in paediatric environments by qualified professionals
Recommendation: Children should always (save in exceptional circumstances, such as emergencies) be cared for in a paediatric environment, and always by healthcare professionals who hold a recognised qualification in caring for children. This is especially so in relation to paediatric intensive …
Unknown
Prevention of Future Deaths reports(55)— showing 50 strongest matches
Lalitaben Patel
Concerns: The coroner identified inadequate systems for assessing and signing off locum consultant surgeons as competent for independent practice, noting that while one hospital had improved, similar risks might exist elsewhere.
Response (Department of Health and Social Care): • The Department of Health and Social Care noted that the specific Trust had addressed concerns regarding recruiting and management practices. • The government welcomed recommendations from a 2013 working … (AI summary)
Responded
Albert Flynn
Concerns: Care staff lacked sufficient training to assess Mr Flynn's condition, leading to a delay in administering food, fluid, and medication for 10 hours. The coroner also identified insufficient staff understanding of prescribed medication's importance and the significance of blood-thinning drugs.
Response (Lester Aldridge LLP): • The organisation stated it would re-emphasise the need to call for qualified assistance during individual staff supervision and new staff induction. • Senior care staff involved in the incident … (AI summary)
Responded
Elsie Mallalieu
Concerns: The patient's placement on an inappropriate ward, where staff lacked training for her high-flow oxygen and high workload impacted observations and record-keeping, raised concerns. Further issues included an inappropriate DNAR order, lack of escalation to higher care, and an unadministered antibiotic drip.
Response (Tameside Hospital NHS Trust): • Training has been provided to orthopaedic doctors regarding consultant involvement and documentation for patient transfers, and on appropriate patient movement from the Trauma Unit. A training schedule for Ward … (AI summary)
Responded
James Stewart
Concerns: A lack of a system for new GP practices to verify medication details for nursing home patients led to critical omissions. The coroner also noted concerns regarding unqualified staff confirming prescriptions, highlighting the need for a robust system from the Clinical Commissioning Group.
Response (Bedfordshire Clinical Commissioning Group): • Bedfordshire Clinical Commissioning Group (BCCG) has developed a protocol for reconciliation of medications for patients transferring into care homes and registering with a new GP. • The developed protocol … (AI summary)
Responded
John Leyin
Concerns: The coroner identified gaps in the dissemination of Trust policy and NPSA guidance, weaknesses in staff training and checking for current competency in procedures. There was also insufficient knowledge regarding the number of trained staff available for such tasks.
Response (Basildon Thurrock University Hospitals NHS Trust): • The Trust overhauled the dissemination of NPSA alerts and guidance, standardising the process for cascading changes to clinical practice. • A Risk and Document Control Manager was appointed to … (AI summary)
Responded
Pauline Edwards
Concerns: The coroner noted that UK hospitals may be unaware of the requirement to accept EU-trained doctors' qualifications, potentially leading to these doctors practicing unsupervised and increasing patient risk.
Response (Department of Health): • The Department stated it is working with the General Medical Council to strengthen processes for confirming equivalent curriculum content for EU medical specialties. • The Department stated it is … (AI summary)
Responded
X Rokeby
Concerns: The coroner noted that despite an action plan to provide advice to transport services on managing spontaneous haemorrhage, the volunteer driver involved in the incident had not received this specific training.
Overdue
George Marks
Concerns: Agency staff demonstrated insufficient understanding of hospital policies and procedures for medication administration, record-keeping on prescription charts and nursing notes, and correct patient handover procedures.
Response (Mayday Healthcare): • Mayday Healthcare implemented monthly SMS reminders to all staff regarding documentation, escalation, medication administration, and compassion. • Consultants are now trained to remind nurses of their basic duties before … (AI summary)
Responded
Peter Wright
Concerns: The coroner identified concerns regarding significant ward understaffing, which led to one nurse caring for 16 patients and performing a drug round alone. Additionally, the report noted a lack of out-of-hours doctor cover at St George's Hospital.
Response (South Staffordshire Shropshire Healthcare NHS Trust1): • The Trust made additional investments in nursing establishments on a number of wards following a review presented in December 2014. • Brocton Ward's staffing establishment for 2015/16 was set … (AI summary)
Responded
Alison Evers
Concerns: The coroner identified a lack of written policy for 'no treats' and insufficient first aid training for health support workers. There was also no policy ensuring a first aid trained member of staff on every shift.
Response (Leeds City Council): • The council stated that introducing a mandatory 'no treats policy' would be inappropriate and detrimental to service users' autonomy, preferring its existing individual risk assessment and support plans. • … (AI summary)
Responded
Willow Davies
Concerns: The coroner noted insufficient support for a newly qualified midwife assisting with a delivery and that midwife allocation did not consider individual experience. The 'Supervisors of Midwives' system at Bedford Hospital required urgent review.
Response (Bedford Hospital NHS Trust): • The Trust requires all midwives to attend mandatory annual resuscitation training, which includes theory and simulation. • A senior midwife in charge assesses the complexity of cases and allocates … (AI summary)
Responded
Dorothy McDermott
Concerns: The coroner noted the inappropriate placement of a vulnerable individual in a residential care home that lacked nursing care and pressure sore training for staff. There was concern that availability was prioritised over the suitability of the placement, and formal guidance is needed for agencies.
Overdue
Wilfred Pearson
Concerns: The coroner noted concerns about the Status Epilepticus protocol's dissemination, inadequate medical notes, and care escalation understanding. The legal authority for detaining an agitated patient without proper authorisation was also questioned.
Response (W Pearson): • The Trust revised its Status Epilepticus policy, integrated it into junior doctor training, and ensured its availability on the intranet. • The Trust reviewed medical staffing rotas, implemented recruitment … (AI summary)
Responded
Ratidzai Sangare
Concerns: Healthcare staff did not recognise Mrs Sangare's need for immediate cardiopulmonary resuscitation, and did not respond immediately to an activated alarm, assuming it was a behavioural issue. There was also limited telephone access for agency staff.
Overdue
Patrick Curran
Concerns: The coroner identified a practice where nursing staff conducted first post-operative reviews and discharges without adequate medical oversight, leading to a patient presenting unwell not being seen by a doctor.
Response (Manchester University NHS Foundation Trust): • The Trust confirmed that post-operative clinics are now led by nurses with a consultant present in the same clinic. (AI summary)
Responded
David Phillips
Concerns: The coroner noted insufficient expertise of the mental health professional conducting the assessment of an older person who self-harmed, and inadequate access for the healthcare professional to the detainee's full medical records.
Overdue
Frederick Chisnall
Concerns: The coroner raised concerns regarding agency staff's documentation practices and their awareness of monitoring clinical changes and urgently seeking medical or nursing help.
Response (St Helens Clinical Commissioning Group): • A safeguarding investigation concluded, identifying concerns regarding agency staff record-keeping and a nurse's responsiveness to clinical changes. • Reflex Agency provided further training to its staff, and St Mary's … (AI summary)
Responded
David Evans
Concerns: The coroner noted that the doctor performing a FAST ultrasound was not properly trained or supervised, and that records of these examinations are not routinely stored. The report further identifies a need for appropriate care escalation when a symptomatic Abdominal Aortic Aneurysm is identified in the emergency department.
Overdue
Sheila Hynes
Concerns: During an operation, a mechanical aortic valve was remounted contrary to manufacturer instructions, without documented rationale or awareness of risks by the surgical team. An untrained scrub nurse was instructed to perform this procedure, and the primary surgeon had not instructed it.
Overdue
Reginald Lewis
Concerns: The patient was left unsupervised without staff awareness, and ward C19 was already stretched with high-dependency patients, leading to junior staff feeling pressured to accept the patient despite reservations about capacity.
Overdue
Jakub Moczyk
Concerns: Pre-fight medical checks were incomplete for boxers, including the deceased's opponent, and medics did not identify this or inform the referee. During the fight, medics did not assess the opponent's fitness after he vomited, relying on the non-medically qualified referee.
Response (Lifeshield Medical Services Ltd): • The organisation stated it is no longer covering boxing events. • The organisation stated it had informed the referee and promoter about which fighters had not received medical examinations. (AI summary)
Responded
Paul Daniels
Concerns: The coroner noted concerns about the 2:1 tree surgeon to groundsman ratio, meaning a lack of immediate support, and that the groundsman was not qualified for aerial work. Communication via shouting and hand signals was also difficult due to tree density and height.
Response (Arboricultural Assocation): • The Association stated it would publish a summary of the events in a safety bulletin for its members. • The Association stated it would circulate the safety bulletin to … (AI summary)
Response (Forestry Commission): • The Forestry Commission's Head of Health and Safety and Technical Training contacted the Arboricultural Association and the Health and Safety Executive. • The Forestry Commission will circulate a safety … (AI summary)
Response (Health and Safety Executive): • The Health and Safety Executive stated it would remind the industry of the importance of applying correct standards for tree work and would promulgate learning points from the incident … (AI summary)
Responded
Simon Graham
Concerns: The coroner noted that lone working arrangements delayed emergency response and CPR, exacerbated by incorrectly labelled keys. Unqualified support workers conducted suicide risk assessments without adequate guidance or training.
Response (NHS Birmingham and Solihull ICB): • The CCG committed to a comprehensive review of its serious incident reporting policy and management processes. • The CCG stated it would undertake an urgent review of its operational … (AI summary)
Response (NHS England): • The Clinical Commissioning Group (CCG) and providers will ensure services are commissioned to provide high-quality risk assessments 24 hours a day, seven days a week. • The CCG and … (AI summary)
Overdue
Terence Bennett
Concerns: The report identifies inadequacies in care, risk, and crisis management plans, insufficient staff knowledge of medical records, and a lack of family involvement. Further concerns include reliance on unqualified staff, insufficient supervision, and poor multi-disciplinary working and handovers.
Response (NHS England): • NHS Improvement (NHSI) stated it would share the Coroner's report findings internally. • NHSI, in partnership with the Care Quality Commission, is delivering a national mental health safety initiative … (AI summary)
Responded
Andrea Franzosi
Concerns: The coroner raised concerns regarding the level of supervision for junior doctors on the ward, particularly when patients are discharged without examination by a more senior practitioner.
Overdue
Daniel Stokes
Concerns: The coroner noted the jury's view that proper systems were lacking for prison healthcare staff to be trained and authorised to administer diazepam when a prisoner is suffering from controlled drug abuse.
Overdue
Polly Drew
Concerns: The recruitment process for a doctor with significant responsibility and access to anaesthetic drugs was inadequate, leading to concerns about the appointed doctor working alone and posing potential risks.
Overdue
Theresa Feehan
Concerns: The coroner identified inadequacies in the practice's medication review system, including the recording of active problems and the correlation between medication and problem lists. Concerns were also raised regarding the identification of medication interactions and the need to audit administrative systems.
Response (CQC): • The Care Quality Commission (CQC) conducted a focused inspection of Lisson Grove Health Centre in March 2019, prompted by the prevention of future death report. • Following challenges from … (AI summary)
Overdue
Mildred Clark
Concerns: The coroner raised concerns that an untrained paramedic was instructed by a hospital doctor via telephone to reduce a suspected hernia, a procedure beyond their role and potentially dangerous if strangulated. There was also concern about staff feeling pressured to avoid hospital admissions.
Overdue
William Vickers
Concerns: The coroner noted that the ambulance crew responding to the prison emergency lacked access to the SCAS radio system. Additionally, the first response did not include a fully qualified paramedic.
Response (HM Prison and Probation Service): • Contingency plans at HMP Woodhill have been updated to prevent delays in receiving emergency vehicles during night state. • New procedures ensure staff assist with ambulance arrival and gate … (AI summary)
Response (CNWL NHS Trust): • New Automatic External Defibrillators (AEDs) with data cards have been installed at HMP Woodhill. • Monthly refresher sessions for AED use and emergency equipment are now held for clinical … (AI summary)
Responded
Robert Rostron
Concerns: The coroner raised concerns regarding HC One's use of agency nurses who lack unit-specific induction, knowledge of policies, or patient care plans, especially when they are the only qualified staff or lead shifts.
Response (The Kind Care Company): • HC-One implemented measures to reduce the likelihood of agency nurses leading shifts without prior unit experience, including block booking. • The company requires agency nurses to submit training records, … (AI summary)
Responded
Trinder Birdi
Concerns: The coroner identified a lack of safeguards when a patient's suicide risk was downgraded by a psychiatric liaison nurse without consultation with the referring GP or a second psychiatric opinion.
Response (North East London NHS Foundation Trust): • A requirement will be introduced for a referral to the on-call psychiatrist when a patient's presenting risk differs significantly from another clinician's assessment. • The Psychiatric Liaison Service assessment … (AI summary)
Responded
Rodney Gates
Concerns: The coroner raised concerns regarding the failure to undertake required patient observations, which was linked to low nursing staff numbers, reliance on agency nurses, and a lack of staff experience and equipment on the ward.
Response (Medway Maritime Hospital): • The Trust implemented electronic observation recording and a NEWS2-based red flagging system across all inpatient wards. • The Trust increased nursing staff establishment following a review and reduced agency … (AI summary)
Responded
Emma Dorman
Concerns: Non-clinical staff significantly influenced decisions regarding patient leave, leading clinical staff to feel unable to object. There was also a persistent lack of psychologist input on the ward for over three years.
Response (South West Yorkshire Partnership NHS Foundation Trust): • Staff understanding of the Patient Flow Procedure and associated roles will be monitored through Matron’s monthly checklists. • The Trust will review the skill-mix for vacant psychology posts, update … (AI summary)
Responded
Joan Coley
Concerns: The coroner identified insufficient training for medical students and junior doctors in taking bloods from central lines, coupled with a lack of formal competency assessment, standard operating procedures, and a system for handing over skills between wards.
Response: • Multiple medical schools and trusts will revise their curricula and induction programmes to enhance teaching on central line risks, safe handling, and the importance of working within personal competence … (AI summary)
Overdue
Adam Brunskill
Concerns: The coroner identified that the employee worked on a roof without prior experience or mandatory safety training. There was an absence of designated supervision and a structured training programme for new or unqualified employees.
Response (Wayne Clarey Roofing Cladding Ltd): • A clear, designated, structured training programme, utilising the Pro-Clad training structure, has been implemented for new and unqualified employees since the inquest. • Wayne Clarey appraises workers daily and … (AI summary)
Response (Health Safety Executive): • Proclad Developments Ltd revised its Contract For Services document to require subcontractors to ensure their workers are trained to a minimum of CSCS card holder status, including a one-day … (AI summary)
Responded
Jan Goodliffe
Concerns: The coroner raised concerns that non-medically qualified social workers conducted home assessments, missing opportunities to obtain expert medical advice on medication interactions for the deceased.
Overdue
Maria Howell
Concerns: The care home lacked qualified nursing staff to reinsert a time-critical RIG tube for a resident with complex needs. Concerns were also raised about staff clinical judgment regarding critically ill patients who required urgent medical attention.
Overdue
Zachariah Richardson
Concerns: The coroner noted insufficient training and supervision for an 18-year-old employee, overdue maintenance and safety defects on FLTs, and a lack of established health and safety systems at the company. No evidence of health and safety improvements was provided almost two years after the death.
Response (DAC Beachcroft): • The Companies consolidated all operations to a single site, ensuring supervision and eliminating lone working at the Elm Farm yard. • New and existing lifting equipment are now subject … (AI summary)
Responded
Carl Wright
Concerns: The coroner noted that inexperienced junior doctors primarily provided medical care and assessed deteriorating patients without easy access to senior input, and blood test results were not reviewed in a timely manner.
Response (Nottingham University Hospital Foundation Trust): • The Trust stated that actions had been taken or were planned in response to learning from the inquest. • The Trust confirmed that oversight of the delivery of these … (AI summary)
Responded
Michael Smith
Concerns: Insufficient staff on duty in the SACU meant medical assessments were not undertaken for the deceased. A single officer on duty also caused a delay in emergency response due to the three-man unlock requirement.
Response (HM Prison and Probation Service): • The HM Prison and Probation Service stated that staffing levels within the Separation and Care Unit (SACU) at HMP Durham are currently above national benchmarking requirements. • A new … (AI summary)
Overdue
Terri Malone
Concerns: The coroner noted issues with initial treatment decisions being made by inexperienced practitioners without senior oversight and patients being discharged quickly for missed appointments, often without their current circumstances or input from other agencies being established.
Response (Herefordshire and Worcestershire Health and Care NHS Trust): • The Trust stated that all trainee psychological wellbeing practitioners discuss every assessment with a Senior Wellbeing Practitioner, who signs off decisions. • It confirmed that the patient's initial assessment … (AI summary)
Responded
Katie Wilkins
Concerns: The coroner noted that Oncology Consultants continue to lead care for APML patients at Alder Hey, despite expert opinion that Haematologists should lead coagulopathy management due to significant bleeding risks. A national shortage of Haematologists limits the Trust's ability to address this.
Response (Department of Health and Social Care): • The Trust implemented changes to ensure patients are now referred to a consultant haematologist rather than an oncologist in similar cases. • Specific guidance on the use and administration … (AI summary)
Responded
Ben Shipley
Concerns: Delays of approximately 12 hours for mental health patients to be admitted after a Section 2 assessment if no bed is available, meaning they cannot be legally detained and remain in A&E without specialist mental health care.
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
Lamarah Scarlett
Concerns: The coroner identified insufficient regulation of home-to-school transport for Special Educational Needs children, citing problems such as transport crew not understanding patient safety plans, missing home visits, lack of mandatory first aid training, and an absence of comprehensive operator inspections.
Response (Department for Education): • The Department for Education contacted Gloucestershire County Council regarding Lamarah’s case. • The Department published updated statutory guidance in 2023, which includes comprehensive recommendations for local authorities on meeting … (AI summary)
Overdue
David Martin
Concerns: The coroner noted inadequate induction for a long-term locum doctor regarding specific cardiology policies. There were also missed opportunities to identify incorrect patient medication, even after the oversight was recognised by staff.
Response (Royal Cornwall Hospitals): • The Trust reviewed and amended the wording in the PCI pack regarding Dual Anti-Platelet Therapy. • Revised wording was approved by the Safer Surgery Group and Forms Review Group, … (AI summary)
Responded
Christiana Dawson
Concerns: The coroner noted a clear risk of future deaths if agency staff at Darnell Grange are not provided with home-specific training or policies, specifically regarding the protocol for moving residents after a fall.
Response (Darnell Grange Nursing Home): • The home has implemented the use of SystemOne to check for medication changes monthly and ensure MAR charts match. • The induction checklist for agency workers has been updated … (AI summary)
Responded
Leslie Swindells
Concerns: Concerns were raised regarding a mental health assistant practitioner's limited training, insufficient understanding of risk, and unclear supervision. The report also noted inadequate patient triage, challenges with telephone assessments, and poor documentation.
Response (GTD Healthcare): • GTD Healthcare ceased the employment of Assistant Practitioners in Mental Health. • The organisation introduced a digital front door system for patient triage and reviewed induction processes for agency … (AI summary)
Response (Department of Health and Social Care): • Departmental officials made enquiries with NHS England and the Care Quality Commission (CQC) regarding the concerns raised. • NHS England reviewed the concerns and provided information to the Department … (AI summary)
Responded
James Keen
Concerns: The coroner noted untrained support workers were conducting physical health checks with confusion about results and their interpretation, and there was no evidence of training or competency checks for this role.
Response (Revon Healthcare): • Revon Healthcare stated that support workers have received additional training specific to physical health monitoring, enabling them to conduct checks, understand normal ranges, raise concerns, and document findings. • … (AI summary)
Responded
Select committee recommendations(25)
#35 —
Recommendation: The Government should set out a clear plan to ensure that all interpreters in the courts are qualified up to a level 6 standard wherever this qualification is available in a language, or an alternative appropriate qualification for rarer languages …
Response attribution not verified
#34 —
Recommendation: It is unacceptable that individuals with qualifications as low as level 1 have been permitted to interpret in the courts. While we welcome the Government’s ambition to ensure that all interpreters working in the courts hold an appropriate level 6 …
Response attribution not verified
#43 — Review children's home staff qualifications and introduce minimum standards for residential childcare workers.
Recommendation: The Department should use its children’s home workforce census to review the levels of qualifications currently held by residential staff. It should also consult on introducing minimum qualification standards for residential childcare workers and work with local authorities to assess …
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
#20 —
Recommendation: NHSE&I explained that the NHS was carrying 100,000 staff vacancies going into the pandemic.58 It said the workforce had been boosted by around 20,000 students; retired NHS staff; and a further 600,000 volunteers (working across a range of public services, …
Response attribution not verified
#8 — Loan agents initially lacked expertise, prompting appointment of specialist provider.
Recommendation: During 2020, the Department had appointed two of its arm’s–length bodies, Arts Council England and Sport England, as its loan agents for the day–to–day monitoring and management of the loans, including relationships with borrowers. However, both Arts Council England and …
Response attribution not verified
#60 — Learning Support Assistants and Teaching Assistants lack adequate SEND-specific training
Recommendation: Learning support assistants and teaching assistants are integral to the effective delivery of SEND support and resourcing their deployment properly can help reduce the need for expensive specialist placements. To sustain and strengthen their contribution, improvements are urgently needed in …
Response attribution not verified
#59 — Introduce requirement for all new headteachers to hold a SEND-specific qualification within four years.
Recommendation: Within four years, the Department should introduce a requirement for all new headteachers to hold a SEND-specific qualification. Ensuring that SEND expertise is embedded at the highest levels of school or multi- 167 academy trust leadership will promote strategic oversight, …
Response attribution not verified
#57 — Mandate at least one Senior Leadership Team member holds SENCO qualifications in all schools.
Recommendation: To strengthen leadership on SEND, the Department should, in the short term, mandate that at least one member of the Senior Leadership Team in every school and every multi-academy trust holds SENCO qualifications. (Recommendation, Paragraph 218)
Response attribution not verified
#49 — Initial Teacher Training and Early Career Framework inadequately prepare teachers for SEND support.
Recommendation: While the Department’s update to the Initial Teacher Training and Early Career Framework is a positive move, it needs to go further to adequately prepare teachers to support pupils with SEND. SEND is still not fully integrated across all training …
Response attribution not verified
#41 — High-quality residential care is essential, requiring improved workforce recruitment and training.
Recommendation: We agree that, for most children, a focus on supporting them to live in a family setting is the right one; however, this should not come at the expense of developing and maintaining high-quality residential care for children who need …
Response attribution not verified
#54 — Mandate SEND continuing professional development for all educators via qualification or module incorporation.
Recommendation: SEND CPD should be made mandatory to ensure that all educators are equipped to meet the diverse needs of children and young people with SEND. This could be achieved through a nationally recognised supplementary qualification in SEND that all existing …
Response attribution not verified
#52 — Mandatory SEND-specific continuing professional development for educators remains absent.
Recommendation: It is deeply concerning that SEND-specific continuing professional development (CPD) is not mandatory. The education workforce must be consistently equipped with up-to-date, evidence-based knowledge through ongoing CPD to ensure an inclusive mainstream with high-quality support for children and young people …
Response attribution not verified
#50 — Implement continuous review for ITT and ECF, increase placements, and mandate specialist setting experience.
Recommendation: The Department for Education must implement a continuous review and update cycle for the ITT and ECF to keep training relevant and effective. It must urgently increase the number of ITT placements and explore the viability of mandating every teacher …
Response attribution not verified
#28 — Work with Security Industry Authority to urgently standardise and improve security guard training across UK.
Recommendation: Independently of the Draft Bill, the Government must work with the Security Industry Authority to look to urgently standardise and improve training for security guards across the UK.
Response status not verified
#27 — UK security industry's low training entry thresholds are unacceptable and concerning.
Recommendation: We are gravely concerned to hear that the UK security industry has one of the lowest entry thresholds in Europe for training. This is simply unacceptable. If the Government is serious about protecting the public from terrorist attacks, improving the …
Response status not verified
#24 — Make career development for early years practitioners an urgent priority to attract and retain staff.
Recommendation: Early years professionals are vitally important. We recommend career development for early years practitioners be made an urgent priority in order to attract and retain more people in the profession. We are concerned about lack of parity of esteem between …
Response attribution not verified
#21 — Monitor staff:child ratio changes, reverse if quality suffers, and develop comparable staff qualifications.
Recommendation: We recommend that the Government’s controversial changes to staff:child ratios be closely monitored and reversed if quality and education outcomes are seen to suffer. If the Government’s goal is truly to “bring the UK in line with Scotland and comparable …
Response attribution not verified
#21 — Skilled Worker visa sponsorship model leaves migrant workers vulnerable to widespread exploitation.
Recommendation: The Skilled Worker visa system is based on a sponsorship model where a migrant’s right to remain in the United Kingdom is dependent on their employer.49 This reliance makes migrant workers vulnerable to exploitation, and there is widespread evidence of …
Response attribution not verified
#18 — Home Office fails to adequately tackle exploitation and unethical practices against migrant care workers.
Recommendation: We remain concerned, however, that the Home Office has not done enough to tackle unethical practices and the exploitation of migrant workers in the social care sector.42 Evidence provided by UNISON highlighted that some employers were exploiting workers’ vulnerability, making …
Response attribution not verified
#29 — Draft Bill misses opportunity to address concerns about security officer education and procurement.
Recommendation: Security at publicly accessible venues is vital in preventing and handling a terrorist attack. Yet there are some serious concerns about the education and procurement of security officers that the Draft Bill does not attempt to address, despite the fact …
Response status not verified
#25 — Engage Local Authorities to provide affordable and flexible mandatory training for early years professionals.
Recommendation: We recommend the Government engage with Local Authorities and seek to address the cost of mandatory training required by early years professionals, such as paediatric first aid and safeguarding courses. Local Authorities should work towards providing 76 Support for childcare …
Response attribution not verified
#23 — Reintroduce a Leadership Quality Fund for diverse early years professional qualifications.
Recommendation: The Government has acknowledged the importance of graduate leadership in the ECEC sector. It should now listen to sector-wide calls for an equivalent of the Graduate Leader’s Fund to be reintroduced. We recommend that this is given a broader name, …
Response attribution not verified
#22 — Review Level 2 English and maths requirements for ECEC staff, prioritising numeracy quality.
Recommendation: In the short term, to prevent the existing qualification levels of falling any further, the Level 2 English and maths requirements for ECEC staff to count in staff:child ratios should be reviewed , and alternatives considered that are more tailored …
Response attribution not verified
#30 — Incorporate provisions into Draft Bill for education and procurement of security at enhanced tier premises.
Recommendation: The Government should consider incorporating provisions into the Draft Bill in relation to education and procurement of security at enhanced tier premises and venues.
Response status not verified
HSSIB safety recommendations(11)
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
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
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
Placement of nasogastric tubes
It would be beneficial if the (recommended) national standardised competency-based training programme for nasogastric X-ray interpretation to confirm nasogastric tube placement will be made a contractual and/or regulatory requirement for all healthcare providers to implement and evidence ongoing compliance with.
Safety Observation
Placement of nasogastric tubes
It would be beneficial if chest X-rays for acutely ill patients were reported by a radiologist, or a radiographer who has undertaken training, to enable them to report on examinations at an appropriate time. The report should include the position …
Safety Observation
Placement of nasogastric tubes
It is recommended that Health Education England coordinates the development and publication of a national standardised competency-based training programme for nasogastric tube placement and confirmation by pH testing. The model may include simulation, observed practical assessment and ongoing competency assessment. …
Safety Recommendation
Placement of nasogastric tubes
It is recommended that the British Society of Gastrointestinal and Abdominal Radiologists, working with Health Education England and the Society and College of Radiographers, develops and publishes a national standardised competency-based training programme for X-ray interpretation to confirm NG tube …
Safety Recommendation
Medicine omissions in learning disability secure units
It may be beneficial if organisations that use mental health nurses to cover shortages of registered learning disability nurses review their clinical model and conduct a training needs analysis. The aim of this would be to identify skills or training …
Safety Observation
Safety risk of air embolus associated with central venous catheters used for haemodialysis treatment
It may be beneficial to consider how junior doctors can be supported to work safely within their level of competence and feel empowered to decline tasks they are not competent to undertake, with specific reference to the safety risks associated …
Safety Observation
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety by ensuring that both permanent and temporary staff in acute medical units are supported in accessing training, achieving competence, and seeking support in completing MUST screening in line with trust processes.
Learning Prompt
CQC inspection actions(79)— showing 50 strongest matches
West Cumberland Hospital
The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.Regulation12(1)(2)(c).
Must Do
The York Hospital
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced midwives to provide safe care and treatment across the service and reduce delays in provision of safe care to reduce the risk of harm for …
Must Do
The County Hospital
The provider must ensure it has sufficient numbers of suitably qualified, competent, skilled and experienced staff who receive such appropriate training to carry out the duties they are employed to perform and ensure staff are trained to the right competency …
Must Do
Scarborough Hospital
The trust must ensure that all bank and agency staff had a full induction and competencies assessed prior to them working in the medical service.
Must Do
Saint Mary's Hospital
The trust must ensure they deploy enough sufficiently skilled and experienced staff to appropriately assess and care for women and birthing people and mitigate risks in a timely manner. Regulation 18(1)
Must Do
Royal Sussex County Hospital
The trust must ensure that staff in theatres are supported to work within their clinical competency and that there are suitable arrangements for monitoring this.
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatpersonsprovidingcareortreatmenttoserviceusershavethequalifications,competence,skills,andexperiencetodososafely.Regulation12(1)(2)(c)
Must Do
Hinchingbrooke Hospital
The service should ensure that only experienced healthcare professionals complete telephone triage calls to ensure safe telephone risk assessments recommendations are safe and accurate.
Should Do
Doncaster Royal Infirmary
The trust must ensure they have enough staff with the right qualifications, skills, training, and experience to keep women safe from avoidable harm and to provide the right care and treatment.
Must Do
Doncaster Royal Infirmary
The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills, and experience to do so safely.
Must Do
Doncaster Royal Infirmary
The trust must ensure it has enough nursing, medical and support staff with the right qualifications, skills, training, and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Must Do
Cumberland Infirmary
The trust must ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely. Regulation 12(1)(2)(c).
Must Do
Chorley and South Ribble Hospital
The service should ensure the maternity assessment service has the right number of qualified staff and the triage telephone line is answered and monitored by a trained midwife.
Should Do
Ambulance Headquarters, Bernicia House
Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.
Must Do
Oakwood
The provider must ensure people are supported by staff with the required knowledge and skill and that staff receive the training and support required to support them in their roles.
Must Do
St Helier Hospital and Queen Mary's Hospital for Children
The service must ensure the role of recovery practitioner is role is carried out by staff with the right level of qualification and additional training.
Must Do
Stamford & Rutland Hospital
The service should ensure that staff providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
Should Do
Stamford & Rutland Hospital
The service must ensure staff competencies are up to date for non-medical prescribers.
Must Do
Royal Berkshire Hospital
The service should continue to review the management of recovery care to ensure this is provided by appropriately trained and competent staff.
Should Do
Epsom General Hospital
The service must ensure the role of recovery practitioner is carried out by staff with the right level of qualification and additional training.
Must Do
Epsom General Hospital
The service must ensure that staff caring for transitional care babies have the appropriate level of qualifications and additional training.
Must Do
Durham Diagnostics and Treatment Centre
The service must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance.
Must Do
Clifton Hospital
The trust must ensure the service has enough staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.
Must Do
Clifton Hospital
The trust must ensure they deploy sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Must Do
Clifton Hospital
The trust must ensure the trust deploys sufficient numbers of suitably qualified, competent, skilled and experienced staff to make sure they can meet people’s care and treatment needs.
Must Do
Basingstoke and North Hampshire Hospital
The trust should ensure staff do not undertake roles outside of their competence level(Regulation12).
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 that women presenting in labour have immediate access to suitable qualified and skilled midwifery staff.
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 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 service must ensure that there is enough staff with the right qualifications, skills, training and experience to provide care and treatment, specifically in relation to medical staffing including taking into account national guidance for the care of children and …
Must Do
The Princess Royal Hospital
The trust should ensure that staff are trained and Qualified in Speciality.
Should Do
Royal Hallamshire Hospital
The trust should ensure that agency staff receive a full induction and understand the service.
Should Do
Queen Elizabeth The Queen Mother Hospital
The trust must ensure all temporary staff are provided with an induction and are competent to work within a paediatric setting.
Must Do
Mount Vernon Cancer Centre
The trust should ensure all eligible nurses receive training and are competent in the use of syringe drivers.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensureithasenoughnursing,medicalandsupportstaffwiththerightqualifications,skills,training,andexperiencetokeeppatientssafefromavoidableharmandtoprovidetherightcareandtreatment.Regulation18(1)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensuretheyhaveenoughstaffwiththerightqualifications,skills,training,andexperiencetokeepwomensafefromavoidableharmandtoprovidetherightcareandtreatment.Regulation18(12)(a)
Must Do
Montagu Hospital, Mexborough
Thetrustmustensureithasenoughnursing,medicalandsupportstaffwiththerightqualifications,skills,training,andexperiencetokeeppatientssafefromavoidableharmandtoprovidetherightcareandtreatment.(Regulation18(1))
Must Do
Montagu Hospital, Mexborough
Thetrustmustensurethatpersonsprovidingcareortreatmenttoserviceusershavethequalifications,competence,skills,andexperiencetodososafely.Regulation12(1)(2)(c)
Must Do
Leighton Hospital
The service must ensure there are enough staff with the right skills, qualifications, competencies, and experience to provide safe care and treatment for women, birthing people, and their babies. This includes staffing of maternity theatres and the maternity theatres recovery …
Must Do
Kettering General Hospital
The servicemust ensure there are sufficient numbers of suitably qualified staff across all clinical areas, to make sure the service can meet people's care and treatment needs. This includes medical, registered nursing and non-registered nursing staff.
Must Do
Kettering General Hospital
The servicemust ensure there are sufficient numbers of suitably qualified staff across all clinical areas, to make sure the service can meet people's care and treatment needs.
Must Do
Chorley and South Ribble Hospital
The trust must ensure staff complete mandatory training in accordance with the relevant schedule and receive sufficient training, supervision, and appraisal to perform their duties competently.
Must Do
Broomfield Hospital
The trust must ensure there are sufficient numbers of suitably qualified, competent, skilled and experienced staff.
Must Do
St Benedict's Hospice
The service should continue to ensure that there are sufficient numbers suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients dependency levels.
Should Do
St Benedict's Hospice
The service should continue to ensure that there are sufficient numbers suitably skilled, qualified and experienced staff in line with best practice and national guidance taking into account patients dependency levels.
Should Do
St Benedict's Hospice
The service must ensure that there are sufficient numbers of suitably skilled, qualified and experienced staff in line with best practice and national guidance.
Must Do
Fairfield General Hospital
The trust must ensure that services are always safely staffed by people with the necessary skills, knowledge and experience.
Must Do
St Helier Hospital and Queen Mary's Hospital for Children
The service must ensure that staff caring for transitional care babies have the appropriate level of qualifications and additional training.
Must Do
PPO death in custody recommendations(3)
The Head of Healthcare
The Head of Healthcare should ensure that agency staff are clinically competent to be assigned to the role of lead emergency nurse.
The HMPPS Executive Director for Wales and the Chief Executive …
The HMPPS Executive Director for Wales and the Chief Executive of NHS Wales should write to the Ombudsman setting out what they have done to satisfy themselves that the nurse-led healthcare service provided at Parc by G4S Medical Services is …
The Governor and Head of Healthcare
review the two incidences in November 2021 where the HCA thought that prison staff gave her authority to move Mr Roalfe out of bed;
IOPC learning recommendations(2)
Recommendation - Bedfordshire Police, May 2022
The IOPC recommends that Bedfordshire Police review its arrangements for managing officers who have returned from extended periods of absence. The review should consider: - the appropriateness of the force's 'return to work' arrangements; - whether they were followed in …
Investigation into woman’s injury sustained whilst in custody – Metropolitan Police Service, …
The IOPC recommends that Hampshire Constabulary ensure that Police Constables who provide cover in custody receive custody-specific training so that they have the appropriate level of knowledge and skills to competently perform their role. This follows an IOPC investigation into …
IMB individual recommendations(3)
Featherstone (2024)
Mental illness is a serious issue within prisons. The compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation that can …
HMPPS
Implemented
Featherstone (2023)
Mental illness is a serious issue within prisons. At Featherstone, the compassionate answer appears to be to locate some of these prisoners in isolation in the CSU, where largely untrained staff attempt to deal with them in a humane way. This is not acceptable and there needs to be a way of speedily transferring these prisoners to more appropriate accommodation …
HMPPS
In Progress
Brinsford (2022)
The amount of time taken to transfer the more vulnerable prisoners with mental health problems is another concern raised regularly. Officers within the inpatient health care are very supportive and compassionate to their patients, however they are not specialist-trained in mental health. Some inpatients have been based in the unit for months before being transferred to more specialist accommodation.
Ministry of Justice
In Progress
Health investigations(15)
Independent investigation: Simeon Claxton, Petersfield, Hampshire (2004) — Rec Recommendation 4
It is recommended that discharge from section 25(a)( MHA 1983) not be undertaken by locum staff or those only involved with the patient for a brief time. There should be extensive consultation before the section is discharged.
south_east
Independent investigation: Michael Green, Nottingham (2005) — Rec R1
The trust should audit whether health care assistants who undertake HoNOS assessments and other risk assessments have been appropriately trained and approved by the trust to do so.
midlands
Independent investigation: Brian Marsh, Swindon (2007) — Rec 18
That the Trust ensures that health care professionals are not given responsibility for service users with Obsessive Compulsive Disorder unless and until they have received appropriate training in the condition, its care and treatment.
south_west
Independent investigation: Arthur Lingard, Grimsby (2004) — Rec 1
To reconsider the practice of employing inexperienced social workers in positions that carry care coordination responsibility for service users with complex mental health needs. If the Trust feels that such appointments are appropriate, then it must ensure that such individuals receive effective supervision both professionally and from a case management …
north_east_yorkshire
Independent investigation: Antonio Tommaso, New Barnet (2014) — Rec 6
The Trust should follow the clinical risk assessment policy and deploy qualified staff to the CPA care coordinator role. If, in exceptional circumstances, a student is considered appropriate for the role, arrangements for role preparation (understanding of the role and appropriate training) should be made with the university programme head …
london
An independent review of the care and treatment received by … — Rec R2
The trust should assure itself that the level of qualified staff on the ward is sufficient, safe, and meets the needs of the patients. There should be arrangements to ensure that escalation processes function effectively to alert senior staff if qualified nursing levels are compromised because of sickness or vacancies.
north_east_yorkshire
Independent investigation into the care and treatment of Mr EF — Rec 6
The Trust should follow the clinical risk assessment policy and deploy qualified staff to the CPA care coordinator role. If, in exceptional circumstances, a student is considered appropriate for the role, arrangements for role preparation (understanding of the role and appropriate training) should be made with the university programme head …
Mr EF who committed a homicide in May 2014. Mr EF was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust
london
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
There is a confusion in Guidelines for Psychiatric Supervisors in the use of the terms ‘consultant’ and ‘supervising psychiatrist’. These should be clarified, particularly with regard to specialist registrars.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 1
Restricted patients should be seen by a consultant psychiatrist acting as psychiatric supervisor. If seen by a specialist registrar there should be regular, recorded consultant supervision.
south_east
Independent investigation: Sharon Wall, Gloucester — Rec 8.3
The second recommendation is for the Trust to review the structure of the staffing arrangements to ensure that an appropriate balance of trained and untrained, senior and junior staff is available to deliver the best quality of safe care in what is a very challenging environment. We will follow this …
south_west
Independent investigation: Jane WheatleyGary Gardiner, Sheffield (2007) — Rec 7
The Trust should produce a policy on the provision of Cognitive Analytical Therapy (CAT) within the Trust and the policy should include clear criteria as to who is qualified to provide CAT and how staff providing CAT are to be trained and supervised. A centralised waiting list should also be …
north_east_yorkshire
Independent investigation: Jenny Foote, Acton (2015) — Rec 4
The Trust must ensure that staff are appropriately skilled and competent to undertake the role of Social Supervisor.
london
Independent investigation: Anthony Rigby, Blackburn (2002) — Rec 21
Those who are appointed as care coordinators should receive training in the role and function of the post clarification
north_west
Investigation into matters relating to Jimmy Savile at Broadmoor Hospital — Rec (3)
Security systems at Broadmoor were underdeveloped and potentially ineffective for much of Savile’s active involvement with the hospital, and were sometimes poorly applied in practice. Nobody but a properly trained and appropriately qualified member of staff should be in a clinical area without supervision. We believe that the much-needed overhaul …
West London Mental Health NHS Trust
london
An independent investigation into the care and treatment of ‘Rachel’¹: … — Rec 3
We are concerned that staff working in general mental health services who find themselves with responsibility for patients with personality disorder may not have sufficient training or support to deliver the most effective care. We therefore recommend that work is undertaken to provide training, consistent with the NICE 2009 guideline, …
Rachel . At the time of the homicide (2014), Rachel was a mental health service user at Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
Detention investigations(1)
Independent reviews(9)
Cavendish Review — Rec 3
The Care Quality Commission should require healthcare assistants in health and support workers in social care to have completed the “Certificate of Fundamental Care” before they can work unsupervised.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 4
All non-surgical procedures must be performed under the responsibility of a clinical professional who has gained the accredited qualification to prescribe, administer and supervise aesthetic procedures.
Health & Social Care
Goldacre Review — Rec Open 37
Ensure experts on code select and oversee code projects Individuals with direct technical expertise in software projects, data infrastructure, RSE, RAP and related work should lead or very strongly guide all funding for projects in this space, just as conventional academics guide awards and oversight for projects delivering single academic …
Health & Social Care
Goldacre Review — Rec S26
Use people with technical skills to manage complex technical problems: create very senior strategic leadership roles for developers, data architects and data scientists; offer leadership training to those in existing technical roles. (Also: train senior leaders in the basics of data analysis, software development, and clinical informatics; but recognise the …
Health & Social Care
Tickell Review of the EYFS — Rec 42
I recommend that the Government ensures that new entry qualifications are of a high standard and, once introduced, reviews whether they succeed in conferring the equivalent status of the NNEB qualification.
Education
Tickell Review of the EYFS — Rec 36
I recommend that the Government retain a focus on the need to upskill the workforce, to commit to promoting a minimum level 3 qualification and to maintain the ambitions for a graduate led sector.
Education
Tickell Review of the EYFS — Rec 7
I recommend that the Skillsactive playwork level 2 award is included as a relevant early years qualification for holiday providers.
Education
Independent review of the physician associate and anaesthesia associate roles: … — Rec 5
Newly qualified physician assistants should gain at least 2 years’ experience in secondary care prior to taking a role in primary care or a mental health trust.
Health & Social Care
Dearing Higher Education Review — Rec 48
We recommend to institutions that, over the medium term, it should become the normal requirement that all new full-time academic staff with teaching responsibilities are required to achieve at least associate membership of the Institute for Learning and Teaching in Higher Education, for the successful completion of probation.
Education
PHSO casework decisions(3)
P-003862 — A dental practice in the Birmingham area
A dental practice failed to identify the need for a second root canal earlier and attempted it without sufficient skills, causing ongoing pain.
NHS in England
Sep 2023
P-001362 — Hampshire Hospitals NHS Foundation Trust
Ms O complained untrained staff performed an incorrect lumbar puncture, resulting in constant pain, inability to work, and career loss.
NHS in England
Apr 2022
P-003831 — Moorfields Eye Hospital NHS Foundation Trust
A supervised junior doctor made mistakes during her 2021 cataract operation, causing sight loss and disorientation.
NHS in England
Sep 2023
LGO / SPSO decisions(12)
NIPSO-202000387 — Western Health and Social Care Trust
The Western Trust approved two special chairs for an autistic child to use in school without properly assessing his needs. The Trust should also have given the school clearer instructions on how the chairs were to be used.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Oct 2024
22-005-432 — Elder Technologies Limited
Summary: We will not investigate this complaint that an introductory care agency withdrew its agreement to provide a care package. We do not have the jurisdiction to investigate.
LGO (Local Government & …
Adult Care Services
Dec 2022
24-007-428 — London Borough of Croydon
Summary: Mr X complains about repeated failures by the Council’s care providers (
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2025
24-023-412 — Community Case Management Ltd
Summary: We will not investigate Miss X’s complaint about the care provider’s handling of concerns she raised about one of her mother’s support workers and of restrictions that were placed on her by the care provider. This is because an investigation would not lead to any worthwhile outcomes.
LGO (Local Government & …
Adult Care Services
Jul 2025
24-001-467 — Suffolk County Council
Summary: We will not investigate this late complaint about Mrs X’s 1997 request to relocate her family member to a care home nearer her home. There is no good reason Mrs X did not complain sooner.
LGO (Local Government & …
Adult Care Services
May 2024
23-010-877 — Stockport Metropolitan Borough Council
Summary: The Council failed to properly respond to Ms X’s concerns about the care her sister received from a care agency acting on behalf of the Council. This led to a prolonged period of short care visits and significant frustration for Ms X. The Council also failed to deal with …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
24-005-757 — K and S Solutions Ltd
Summary: We cannot investigate this complaint about a Care Provider allegedly not paying rent. This is because the actions complained about do not relate to the provision of adult social care.
LGO (Local Government & …
Adult Care Services
Jul 2024
24-023-407 — Salyx Care Limited
Summary: We will not investigate Ms X’s complaint about the Care Provider’s respite home care for her mother Mrs Y. There is insufficient significant injustice to Ms Y or her family caused by the matters complained of to warrant us investigating.
LGO (Local Government & …
Adult Care Services
Jul 2025
23-011-164 — Bedford Borough Council
Summary: Ms X complains the Council’s care provider, Bluebird Care Bedford, failed to meet her needs properly. The evidence shows there has been no fault by the Council.
LGO (Local Government & …
Adult Care Services
Not Upheld
Nov 2024
23-019-969 — City of Wolverhampton Council
Summary: We will not investigate this complaint about adult social care provided at home. The care provider acting on behalf of the Council has accepted fault, apologised for the impact, and acted to improve future service. It is unlikely we would achieve anything further by investigation.
LGO (Local Government & …
Adult Care Services
Upheld
Nov 2024
23-020-562 — Kent County Council
Summary: We will not investigate this late complaint about the quality of domiciliary care. There is not a good reason for the delay in the complainant bringing the matter to the Ombudsman.
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
23-015-615 — Aadi Trading Ltd
Summary: Mrs X complained the Care Provider failed to provide her mother (Y) with an adequate standard of care between October and November 2023. The Care Provider was at fault for poor record keeping and not carrying out care visits in line with when Y needed her medication. It was …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2024
Domestic Homicide Reviews(5)
West Berkshire — recommendation 8
Bespoke advanced mental health telephone counselling skills must be provided for all staff and refreshed biannually. Staff should not work in these services without undertaking a competency-based training.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Cardiff — recommendation 1
That an appropriately phased programme of training be developed to ensure that Social Work Assistants who will be required to undertake assessments and reviews have a relevant social care qualification at Level 4 or above.
Adult Social Services
Adult Social Services
Stoke-on-Trent — recommendation SSOTP.b
Unqualified Our Health 5-19 staff who have direct contact with children should receive training on domestic abuse and the impact of this on children. The Partnership Trust currently offers a half day in house training which would appropriately meet this need.
Staffordshire and Stoke-On-Trent Partnership NHS Trust
Staffordshire and Stoke on …
East Sussex — recommendation KSSCRC3
KSS CRC to ensure that the competencies of temporary and/or agency staff are checked.
Kent Surrey and Sussex Community Rehabilitation …
Essex Community Rehabilitation Company
Wokingham — recommendation R1
A review of whether assessments of people caring for those with mental health difficulties, be undertaken by a specialist mental health practitioner or a generalist practitioner should be undertaken.
Wokingham Borough Council