Urgent care pathways
Deficiencies in urgent care pathways for serious but non-immediately life-threatening conditions, leading to delays and poor outcomes.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
3 inquiry recs
233 PFD reports
10 committee recs
18 HSSIB recs
206 CQC actions
28 PPO recs
13 IOPC recs
1 PHSO rec
4 IMB reports
3 Scottish FAIs
40 DHR recs
1 PHSO decision
26 CQC enforcement actions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(3)
R95 — Blue light protocol for at-risk registers
Recommendation: HSCTs must develop registers of those at risk of requiring unplanned inpatient treatment, similar to the NHS England ‘blue light protocol’, in order to target community resources efficiently and prevent the person having to leave their home in the community.
No response yet
MAI-77 — Review procedures for patient dispatch to hospitals
Recommendation: North West Ambulance Service should review its procedures with local NHS trusts to ensure that it has effective policies in place for quickly dispatching patients injured in a Major Incident to an appropriate hospital.
Gov response: Accepted in full
Accepted
MAI-149 — Healthcare provision under Protect Duty
Recommendation: The Home Office should consider whether the requirement for adequate healthcare provision at events is a topic that should also be addressed by the Protect Duty.
Gov response: Accepted in full
Accepted
Prevention of Future Deaths reports(233)— showing 50 strongest matches
Dorothy Townley
Concerns: Insufficient direct communication between District Nurses and the GP, especially regarding patient condition, wound care, and urgent blood tests. The District Nursing Team also lacked knowledge and training in burns treatment, and their wound assessment chart was inadequate.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated it influences general practitioner training through its established GP Curriculum, which includes guidelines for best practice. • The College noted that its … (AI summary)
Responded
Barnabas Newlyn
Concerns: The coroner noted that road transfer times for critically ill patients, especially neurosurgical emergencies, between distant hospitals and specialist facilities may not allow sufficient time for life-saving interventions. Healthcare staff needing urgent transfers were advised to consider air transfer first.
Response (NHS England): • Interim guidance will be issued to acute hospitals within the next month, covering the maintenance of equipped transfer bags, correct protocols for uncommon events, and training for critical care … (AI summary)
Responded
Chloe Grace Flavell
Concerns: The coroner noted concerns regarding the management of the reception area before triage, which could lead to significant delays in providing immediate care, particularly for children. A more appropriate and efficient system is needed to minimise these delays.
Overdue
Andrew John Fallon
Concerns: Insufficient staffing levels in the Emergency Department led to doctors being overwhelmed and significant treatment delays, particularly for patients with severe health issues, exacerbated by the volume of minor complaints.
Overdue
Albert James Hand
Concerns: Concerns were raised about a patient with a head injury waiting over 90 minutes for ambulance conveyance. The coroner noted insufficient ambulance crews in the area and protocols for emergency calls that may put patients at risk.
Response (East of England Ambulance Service NHS Trust): • The Trust commissioned a Clinical Capacity Review and shared its findings with Clinical Commissioning Groups to address ambulance availability. • The Trust initiated a recruitment drive to increase staff … (AI summary)
Responded
Jacqueline Allwood
Concerns: The coroner identified concerns regarding the absence of an agreed protocol for managing calf pain and suspected DVT at the Urgent Care Centre. Additionally, questions were raised about a specific GP's understanding and acceptance of normative diagnostic standards and the adequacy of practice changes.
Response (NHS England): • The Urgent Care Centre and Cator Medical Centre reported amendments to their triage process and the introduction of a new screening form. • The GP stated that the case … (AI summary)
Overdue
Keith Martin
Concerns: The coroner noted significant delays in Mr Martin's assessment, tests, and senior review in A&E, alongside concerns about the lack of appreciation for his symptoms and test results. Further issues included slow pharmacological treatment, unclear chest pain management protocols, and ineffective documentation.
Overdue
Selina Broadhurst
Concerns: The coroner raised concerns that NICE Guidelines for head CT scans, which require obvious neurological signs, may lead to missed or delayed diagnosis of severe brain injuries in frail elderly patients.
Overdue
Peter Galea
Concerns: The coroner noted limited mechanisms for agencies to break the cycle of referrals to allow for more detailed mental health assessments, and expressed concern about limitations on GPs directly admitting patients to a place of safety.
Overdue
Keith Thomas Graham
Concerns: The coroner called for a review of procedures for seriously injured trauma patients at A&E, specifically regarding the summoning of on-call clinicians, CT scanning protocols, and reducing delays between patient presentation and surgery.
Overdue
James Sutton
Concerns: The London Ambulance Service did not automatically link specific risk factors, including age, fall height, and anti-clotting medication, to trigger an 8-minute emergency response for Mr Sutton.
Overdue
Stephen Palmer
Concerns: Concerns were raised regarding delays in surgical assessment and recognition of patient deterioration, along with an inappropriate unit transfer. The report also identified suboptimal clinical management, inadequate ward rounds, and a complete failure of the hospital's CT scanning service.
Overdue
Stephen Bedford
Concerns: Concerns were raised regarding the regular assessment of emergency care staff for life support standards, and if paramedics with advanced life support training should be mandated for all Code Red and PPCI transfers. Further issues included training for ECG machines for certain staff, and specific guidance for communicating with relatives.
Overdue
Gianna Khan
Concerns: A patient presenting with a head injury was streamed to a GP clinic instead of the Emergency Department, contrary to medical advice that all suspected head injuries should be referred to the A&E Team.
Response (Luton NHS Clinical Commissioning Group): • Children with head injuries, children conveyed by ambulance, and babies 6 months and under were immediately excluded from the streaming protocol. • These patient groups are now assessed and … (AI summary)
Responded
Thomas Smith
Concerns: The coroner identified gaps in complete and accurate handover information between primary and secondary care, raising concerns about the prioritisation of children's cases in out-of-hours services. The report also noted a need to revisit national guidance on pre-hospital antibiotics for suspected meningitis and highlighted a fragmented approach to patient care in hospitals where nursing staff concerns were not promptly acted upon.
Overdue
Mary Hallworth
Concerns: Medical attention for the deceased was not sought or considered for 24 hours following a fall, despite the person experiencing pain.
Overdue
Kirk Williams
Concerns: The coroner noted a mismatch in perception between Cleveland police officers and local A&E staff regarding the treatment of violent or aggressive patients with medical emergencies. There is a lack of dialogue and clear guidelines between the Constabulary and A&E departments to address these misunderstandings.
Response (South Tees Clinical Commissioning Group): • A meeting was held between NHS and police representatives, resulting in the agreement of new guidelines for managing aggressive detainees in A&E departments. • Cleveland Police stated it was … (AI summary)
Response (Cleveland Police): • Cleveland Police stated that agreed guidance, developed jointly with two Trusts, would be issued to staff. • The guidance outlines procedures for managing detainees with mental health issues, serious … (AI summary)
Response (NHS England): • NHS England stated it would consider the case further with its Northern Regional Medical Director to determine if changes to relevant policies and guidance were needed. • NHS England … (AI summary)
Overdue
Sandra Bodrozic
Concerns: Concerns were raised about delays in securing an informal hospital admission for the patient and a lack of exploration of private bed options. Further concerns noted delays in arranging Mental Health Act assessments, with no clear protocols for timeframe or communication regarding urgent assessment options.
Overdue
Lara Mamula
Concerns: The Isle of Wight Ambulance Service did not appreciate the gravity of Loeys-Dietz syndrome and its predisposition to aortic aneurysms, which impacted their advice regarding hospital assessment.
Overdue
Anthony Huggan
Concerns: The coroner noted the absence of an appropriate out-of-hours service for drug addiction, which placed an undue burden on emergency services. Concerns were also raised about the timeliness of follow-up checks for patients self-discharging after an overdose.
Response (Bury Council): • The One Recovery Bury service, implemented in April 2014, provides flexible opening hours, including weekends and evenings. • Plans are being developed for early 2015 to enhance flexible service … (AI summary)
Responded
Mikey Hornby
Concerns: Concerns were raised that out-of-hours staff did not immediately send the child to hospital for an infected umbilical cord, and a doctor later failed to appreciate the seriousness of the situation, sending the child home. The coroner also noted the GP surgery's lack of facilities for simple blood tests.
Response (Bridgewater Community Healthcare NHS Trust): • The Trust implemented national NICE guidance on feverish illness in children and uses the Paediatric Early Warning Score (PEWS) system in its out-of-hours service. • A Root Cause Analysis … (AI summary)
Responded
Kevin Hoey
Concerns: The coroner noted that the East of England Ambulance Service NHS Trust should consider introducing training, similar to the EMAS Paramedic Pathfinder Programme, to help paramedics identify suitable patients for community treatment versus hospital transfer.
Response (East of England Ambulance Service): • A clinical manager met with East Midlands Ambulance Service colleagues to discuss their Paramedic Pathfinder Programme. • The Paramedic Pathfinder Programme was discussed at the Trust’s Clinical Quality and … (AI summary)
Responded
Noel Jones
Concerns: The coroner noted a delay in Mr Jones's acceptance by Worcestershire Royal Hospital likely impacted his survival. The hospital also lacked out-of-hours services for vascular surgery and interventional radiology.
Response (Worcestershire NHS Trust): • The Trust confirmed it had reviewed its processes for out-of-hours or on-call arrangements for vascular surgery or interventional radiology for critically ill patients requiring transfer. (AI summary)
Responded
Patricia Chapman
Concerns: The revised training and flowchart for community hospital staff does not include a mechanism for obtaining emergency medical advice from experts in acute hospitals, which could be beneficial in urgent situations.
Response (County Durham and Darlington NHS Trust): • The Trust confirmed that all qualified staff at Sedgefield Community Hospital received training in deteriorating patient management and hypoglycaemia. • The Trust introduced an operational procedure for community hospital … (AI summary)
Responded
Sally Ellison
Concerns: The coroner noted a delay in sending a urine sample for legionella analysis despite early recognition of atypical pneumonia, which may have delayed optimal treatment. Concerns were also raised regarding the lack of a rapid testing and reporting service for legionella.
Response (NHS Wales): • Changes have been made within the laboratory at Glan Clwyd to enable the immediate reporting of all cases where the CRP is greater than 300. • The Pathology Clinical … (AI summary)
Responded
George Boulton
Concerns: The coroner identified insufficient escalation protocols for suspected stroke patients across primary care, bed bureau, and ambulance services, leading to delays in emergency response and risking timely diagnosis and treatment options.
Response: • East Midlands Ambulance Service will discuss workforce changes required to implement the Advanced Medical Priority Dispatch System for GP and Health Care Professional urgent calls, and will communicate to … (AI summary)
Overdue
Anne Wilson
Concerns: The coroner noted gaps in the Metropolitan Police Service's welfare check policy, including insufficient training for staff, lack of communication with the London Ambulance Service and GPs, and a failure to inform a GP when a welfare check request was downgraded.
Response (London Ambulance Service NHS Trust): • A copy of the Metropolitan Police 'External Briefing Note welfare checks dated March 2014 updated March 2015 V1' was provided. • The updated policy will be incorporated into the … (AI summary)
Overdue
Robert Hogg
Concerns: The coroner noted concerns that NHS Pathways for toddlers and children may not effectively identify very sick children, and that no changes have been made to address this ongoing risk.
Response (NHS Pathways): • NHS Pathways stated there were no grounds for the claim that its toddler/child assessment tools were failing to identify very sick children. • NHS Pathways stated it had previously … (AI summary)
Responded
James Adams
Concerns: Concerns were raised regarding the shortage of acute psychiatric beds in Cornwall and inadequate staffing at designated mental health places of safety. This leads to patients being inappropriately detained in police cells or transported out of county.
Response (James Adams): • The working relationship between Devon and Cornwall Police and local Mental Health Services has been improved, and a Memorandum of Understanding has been drawn up. • Kernow CCG has … (AI summary)
Responded
Caroline Robey
Concerns: Community healthcare providers did not use a sepsis screening tool, missing opportunities for diagnosis and emergency referral. An NHS England patient safety alert regarding a UK sepsis clinical toolkit had not been recognised or adopted.
Response (NHS England): • An individual practitioner was requested to reflect on record keeping and the diagnosis and treatment of patients with suspected sepsis at their next appraisal. • NHS England highlighted the … (AI summary)
Response (ROBEY Responses): • East Midlands Ambulance Service introduced an updated adult and paediatric sepsis screening tool in March 2015. • Loughborough Urgent Care Centre developed an organisational sepsis policy and provided sepsis … (AI summary)
Overdue
Steven Jackson
Concerns: The report highlights a paramedic's ineffective use of the sepsis screening tool and identifies a need for effective training for ambulance staff on the tool's application and appropriate patient conveyance to hospital.
Overdue
Christine McNamara
Concerns: The coroner identified a lack of pathways for post-ERCP patients with complications and issues with out-of-hours radiography referral, noting no surgical consultant was on call from Maidstone during the working week.
Response (Maidstone and Tunbridge Wells NHS Trust): • A new pathway for suspected post-endoscopy complications was devised and implemented in January 2016, with a review scheduled for October 2016 to assess its clarity. • The Trust stated … (AI summary)
Responded
Leslie Summerfield
Concerns: The coroner raised concerns about the withdrawal of urgent endoscopy services at Trafford General Hospital, questioning the safety of treating acutely unwell patients requiring such essential procedures at the facility. This led to patient transfers and delays in accessing critical care.
Overdue
Michael Valentine
Concerns: The coroner raised concerns that an urgent mental health act assessment application was rejected without the GP being notified, and urgent rejections were not clearly marked or accompanied by a phone call to the doctor.
Response (Michael Valentine): • The practice conducted an audit of post on 23 February 2016. • A re-audit was undertaken on 22 March 2016. • The practice met with secondary care psychiatry colleagues … (AI summary)
Response (Michael Valentine Response2): • Staff rejecting urgent referrals will contact the referrer directly to confirm the outcome of their assessment. • Advice will be sought from the Local Medical Committee regarding how learning … (AI summary)
Responded
Douglas Kay
Concerns: The coroner identified significant confusion and uncertainty regarding policies for transferring patients with gastrointestinal bleeding within the Trust. Senior staff at Bassetlaw Hospital were also unaware of the new Doncaster Hospital service's operational details, particularly out of hours.
Response (DBH Trust): • A new Upper GI Bleed Transfer Policy for Bassetlaw Hospital has been developed. • All staff will be made aware of the transfer policy through the Clinical Site Manager … (AI summary)
Responded
David Mostari
Concerns: The coroner noted an inadequate system for ensuring urgent diagnostic tests, such as x-rays and ultrasounds, are performed without delay, particularly for patients admitted at weekends.
Response (D Mostari): • The Trust developed a position statement and action plan. • The Trust is implementing the position statement and action plan to ensure a robust system for urgent diagnostic tests … (AI summary)
Responded
Sandra Wood
Concerns: The NHS Trust does not have facilities for routine CT scans on weekends, and the urgent scan procedure can cause delays, as a required scan was postponed until after the weekend.
Response (sandra wood): • The Trust reiterated to clinical staff the processes in place for 24/7 availability of CT scanning for urgent cases. (AI summary)
Responded
Marilyn Anson
Concerns: Concerns were raised regarding the long wait times for urgent 'hot foot' clinic referrals, which led to patient deterioration. The coroner noted the need for a review of patient prioritisation, resource allocation, and a standardised referral process with clearer guidance for community nurses.
Overdue
Eric Gaskell
Concerns: The Royal Bolton Hospital's policy preventing A&E doctors from issuing standard prescriptions, coupled with limited hospital pharmacy opening hours, restricts patients' 24-hour access to essential medications. This gap in provision could contribute to future deaths.
Response (Eric Gaskell): • A memorandum was issued to all wards and departments concerning the supply of medicines outside of normal hours. • The existing stock list of over-labelled and pre-packed medicines in … (AI summary)
Responded
Vanessa Dadswell
Concerns: The coroner highlights the need for an intermediate referral option between the existing '4-hour' and 'within 5-day' periods for urgent mental health service referrals, alongside effective management of this new category.
Response (Vanessa DADSWELL): • The Trust implemented a new system enabling Triage Team Leaders to book priority appointments directly and fast-track urgent referrals for assessment within 24 hours or 2-3 days. • A … (AI summary)
Overdue
June Parkes
Concerns: Deficiencies in provision and protocols for urgent and emergency endoscopies and surgery were identified. Concerns also included staff compliance with the NEWS system, record-keeping, and criteria for doctor presence during critical patient transfers.
Overdue
Pamela Conway
Concerns: The coroner raises concerns regarding ongoing unacceptable delays for patients waiting in ambulances, which also makes ambulance resources unavailable. Additionally, patient flow problems persist within Maelor Hospital's Emergency Department.
Response: • The Health Board has enclosed two working action plans. • The action plans will be scrutinised by the Assistant Director of Nursing and the Hospital Medical Director. • The … (AI summary)
Responded
Harry Gill
Concerns: The coroner raises concerns about the robustness of the NHS 111 vomiting pathway, noting that only one out of four calls received an appropriate response.
Response (NHS England): • NHS Pathways concluded a review of its vomiting questions and enhanced their content. • The vomiting questions were amended to include more specific prompts for coffee ground vomit, blood, … (AI summary)
Responded
Imad Hassan
Concerns: The coroner identified a lack of a formal backup plan for patients requiring PCI when primary hospitals cannot accept them, and no agreed pathway for unconscious STEMI patients needing tertiary services. This absence of capacity and clear pathways increases the risk of death.
Response (Hassan): • Cwm Taf University Health Board worked with WHSSC and provider units to develop an interim solution for PCI procedures. • An agreed interim position between the respective organisations was … (AI summary)
Response (Imad Hassan): • United Hospitals University Bristol Trust has confirmed it will accept patients in the event of insufficient critical care capacity in South Wales. • The usual regional PPCI centre will … (AI summary)
Overdue
David Moran
Concerns: The coroner noted imprecise guidance for categorising referral urgency, specifically the lack of a default to urgent when screening was not possible or in cases of doubt. There were also concerns regarding ineffective communication between administrative and clinical staff.
Response (5 Borough Partnership NHS trust): • Standard Operating Procedures (SOPs) have been developed and implemented for the Assessment Team, establishing a default to urgent face-to-face assessment within 72 hours for uncertain referrals. • The Assessment … (AI summary)
Responded
Teresa Dennett
Concerns: The coroner identified concerns regarding the absence of a clear pathway for referral for life-saving neurosurgery, alongside issues with diagnostic imaging and the input from stroke physicians in appropriate cases.
Response (Nottingham University Hospitals NHS Trust): • A new protocol has been written and adopted for patients requiring life-saving emergency intervention, ensuring acceptance for transfer irrespective of critical care bed state. • The development of an … (AI summary)
Response (Sheffield Teaching Hosipals NHS): • The Trust drafted a local protocol for the admission of patients requiring emergency neurosurgical procedures. • The draft protocol has been shared with Nottingham University Hospitals NHS Trust. • … (AI summary)
Response (NHS England): • NHS England sought assurance from neurosurgical centres and referring hospitals in the Midlands, East, and North regions regarding protocols for emergency neurosurgery referrals. • NHS England requested that informal … (AI summary)
Overdue
Terence Millington
Concerns: The coroner identified issues with an on-call senior doctor's arrangements for being contacted by telephone, the next on-call consultant's prompt attendance due to distance, and the incorrect fulfilment of a request for two packs.
Response (Sheffield Teaching Hospital NHS Trust): • The Trust's consultant discussed the incident with the senior doctor, and local induction for ENT staff now includes guidance on remaining contactable, with plans to incorporate this into the … (AI summary)
Responded
Ceriann Richards
Concerns: Significant handover delays at two district general hospitals led to an ambulance being delayed in its dispatch to the deceased. These delays exceeded the agreed 15-minute handover time and have worsened since 2016.
Response: • The Health Board established an Urgent Care Board to oversee urgent and emergency care services. • It implemented a Standard Operating Procedure and escalation protocols to manage bed capacity … (AI summary)
Response (Welsh Government): • The Welsh Ambulance Services NHS Trust has enhanced its clinical desk, established alternative pathways, and implemented a falls response service and a frequent callers project to limit hospital conveyance … (AI summary)
Responded
Frederick Bevan
Concerns: The coroner noted concerns about the handover of incident history to emergency services, identifying a risk that if the direct witness does not provide information, incorrect details may be given, potentially impacting treatment.
Overdue
Derek Turnbull
Concerns: The coroner noted a delay in summoning an ambulance for a patient with a known falls history, on Warfarin, and with an obvious head injury. This occurred despite the clear need for immediate hospital review, leading to a recommendation for policy and procedure review.
Overdue
Select committee recommendations(10)
#10 — Establish a 24/7 Neighbourhood Mental Health Centre in every community.
Recommendation: We believe there should be a 24/7 Neighbourhood Mental Health Centre in every community. (Recommendation, Paragraph 92)
Response attribution not verified
#1 —
Recommendation: Homecare medicines services have significant potential to deliver high-quality care to patients in their homes and reduce pressure on hospitals. They should be a key part of future planning and resourcing for the NHS.
Response attribution not verified
#6 —
Recommendation: We therefore recommend that NHS England completes and publishes evaluations of NHS 111 call first services as soon as is practicable, including learning from those evaluations and the implications for any future iterations of the service.
Response attribution not verified
#27 —
Recommendation: We welcome the news that the Government and NHSE/I are piloting a ‘111 dial first’ scheme to support the triaging of patients before they attend A&E departments. The introduction of an expectation that a patient will call first before walking …
Response attribution not verified
#5 —
Recommendation: Managed well, we see enormous potential for a beefed-up version of 111 to regulate the demands on emergency departments and ensure that patients get the right care, in the right place, at the right time. However, we acknowledge concerns that …
Response attribution not verified
#1 — Evidence taken from DHSC and NHS England on access to unplanned or urgent care.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health & Social Care (the Department) and NHS England about access to unplanned or urgent care.1
Response attribution not verified
#3 — Clearly set out causes of urgent care performance variation and initiatives to improve standards.
Recommendation: The quality of patients’ access to urgent and emergency care depends too much on where they live, particularly with wide variation in ambulance response times. There is significant regional variation in the performance of services for urgent and emergency care. …
Response attribution not verified
#4 — Ensure all FGM survivors access timely, essential support and specialist care nationwide
Recommendation: The Government should ensure that all FGM survivors can access the essential support and care they need in a timely manner. While some variation in service provision may be necessary to reflect local prevalence rates, higher-prevalence areas should offer funded …
Response attribution not verified
#32 — Need for Integrated Care Systems to simplify patient interface and improve first-contact access.
Recommendation: Integrated Care Systems should prioritise simplifying the patient interface with the NHS by improving access, triage and referral across first-contact NHS organisations including general practice.
Gov response: Accept. The Department accepts this recommendation and agrees that this should be a priority for Integrated Care Systems. NHS England have already issued a framework to support conversations between Integrated Care System teams and GP …
Accepted
#31 — Unacceptable patient uncertainty accessing first-contact care through new NHS organisations.
Recommendation: Primary Care Networks and Integrated Care Systems offer an opportunity to better integrate care around people. It should not be the case that patients face so much uncertainty about where to turn to if they have a new or urgent …
Response attribution not verified
HSSIB safety recommendations(18)
Timely detection and treatment of cauda equina syndrome
It may be beneficial for NHS spinal networks in England to implement services and processes to support timely access to MRI for patients with suspected cauda equina syndrome, in line with national guidance to be developed by the British Association …
Safety Observation
Timely detection and treatment of cauda equina syndrome
It may be beneficial for all hospitals where patients with potential cauda equina syndrome may present to have access to MRI scanning and reporting 24 hours a day, 7 days a week.
Safety Observation
Medication not given: discharge from an acute hospital to the community
How does your organisation make sure that patients have access to specialist diabetes support including out of hours?
Learning Prompt
Management of acute onset testicular pain
It is recommended that NHS England/Improvement works with relevant stakeholders to develop guidance for handling telephone advice/triage in primary medical care settings.
Safety Recommendation
Management of acute onset testicular pain
It is recommended that the NHS England/Improvement ‘Getting It Right First Time’ (GIRFT) programme ensures that testicular torsion/acute testicular pain is included on the checklist of emergency pathways to be considered by the newly established Urology Area Networks across England.
Safety Recommendation
Clinical decision making: diagnosis of pulmonary embolism in emergency departments
It may be beneficial for emergency departments and same-day emergency care units to have rapid access to recommended imaging for patients who require it for the diagnosis of pulmonary embolism.
Safety Observation
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
It may be beneficial, when dealing with a novel virus, for consideration to be given to the benefits of a face-to-face assessment for callers with comorbidities.
Safety Observation
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety by reviewing policies, processes, and procedures in acute medical units to ensure they provide clear and easily accessible pathways to refer patients to dietetics or speech and language services.
Learning Prompt
Timely detection and treatment of cauda equina syndrome
It may be beneficial for hospital trusts without 24 hours a day, 7 days a week MRI provision and the potential to see patients with suspected cauda equina syndrome to consider expanding the skills of their radiographers to allow out-of-hours …
Safety Observation
Undetected button/coin cell battery ingestion in children
It is recommended that the Association of Ambulance Chief Executives agrees guidance that can inform its members on the competency and authority for staff to convey, refer and discharge children under five years who are subject to 999 calls.
Safety Recommendation
Learning from maternal death investigations during the first wave of the COVID-19 pandemic
advice on accessing further medical care
Learning Prompt
NHS 111’s response to callers with Covid-19-related symptoms during the pandemic
HSIB recommends that NHS England reviews the risks associated with increased use of telephone triage in response to national healthcare emergencies. Consideration should be given to applying any recommendations of this review across telephone triage services within the wider healthcare …
Safety Recommendation
HSIB’s local investigation pilot: shared learning for local healthcare systems
HSIB national investigation ‘Harm caused by delays in transferring patients to the right place of care .’
Learning Prompt
Patient care in temporary care environments
Does your organisation have aligned processes across different departments, including the availability of specialty services to help facilitate the movement of patients to the right place of care as soon as possible?
Learning Prompt
Transfer of critically ill adults
It is recommended that the Department of Health and Social Care should co-ordinate the development of national guidance, with the arm’s length bodies, for the transfer of critically ill adults, both in planned and emergency situations.
Safety Recommendation
Provision of mental health care to patients presenting at the emergency department
It is recommended that NHS England ensures there is a sustainable funding model to support 24/7 urgent and emergency mental health liaison services in acute general hospitals with emergency departments.
Safety Recommendation
Variations in the delivery of palliative care services to adults
Support collaboration between health and care organisations to define clear routes of support for people in and out of normal working hours to ensure they know how to access help for palliative care and end of life needs.
Safety Action
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
Health and care organisations can improve patient safety by allocating a point of contact for patients and/or their carers when people are discharged from services out of normal working hours. This will ensure patients and their carers are able to …
Safety Observation
NCEPOD recommendations(47)
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Testicular Torsion
Wording not shown. See the report on NCEPOD's website.
Testicular Torsion
Testicular Torsion
Wording not shown. See the report on NCEPOD's website.
Testicular Torsion
Juvenile Idiopathic Arthritis
Wording not shown. See the report on NCEPOD's website.
Juvenile Idiopathic Arthritis
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
Acute limb ischaemia
Wording not shown. See the report on NCEPOD's website.
Acute limb ischaemia
Emergency procedures in children and young people
Wording not shown. See the report on NCEPOD's website.
Emergency procedures in children and young people
Emergency procedures in children and young people
Wording not shown. See the report on NCEPOD's website.
Emergency procedures in children and young people
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Delay In Transit
Wording not shown. See the report on NCEPOD's website.
Delay In Transit
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
CQC inspection actions(206)— showing 50 strongest matches
Worcestershire Royal Hospital
The trust should ensure timely admission to the high dependency area of Acute Respiratory Unit.
Should Do
West Suffolk Hospital
The service must ensure it implements a tool to safely triage women in the maternity day assessment unit and labour suite triage.
Must Do
Westmorland General Hospital
The trust should consider completing the urgent and emergency care plans that have been delayed so that these can feed into the medicine care group strategy.
Should Do
Westmorland General Hospital
The trust must operate an effective clinical escalation system to ensure stroke care and treatment is assessed and implemented in a timely way.
Must Do
Westmorland General Hospital
The trust must ensure that robust action plans to improve and manage the flow of patients through the emergency department are put in place, taking into account known factors contributing to the hindrance of flow through the department and mitigating …
Must Do
Westmorland General Hospital
The trust must ensure that stroke patients receive treatment in line with best practice guidance and in line with the trust’s stroke pathway so there are no delays to treatment.
Must Do
University Hospital Aintree
The trust must ensure that work continues to improve performance against national urgent and emergency care standards; including time to triage, time to clinical review, and time in the department.
Must Do
The York Hospital
The trust must ensure that that care meets the needs of service users by improving referral to treatment times.
Must Do
The York Hospital
The service must ensure the service continues to work to improve the following performance standards at Scarborough hospital; the median time from arrival to treatment. the percentage of patients admitted, transferred, or discharged within four hours. the monthly percentage of …
Must Do
The York Hospital
The trust must ensure that that care meets the needs of service users by improving referral to treatment times.
Must Do
The Tunbridge Wells Hospital at Pembury
The service must ensure systems and processes for maternity triage are reviewed to deliver a safe service in line with national guidance.
Must Do
The Royal Oldham Hospital
The trust must improve the flow of patients through the emergency department and the hospital so that patients are assessed, treated, admitted and discharged in a safe, timely manner.
Must Do
The Queen Elizabeth Hospital
The service must ensure women and birthing people are seen within appropriate timelines by medical staff when presenting to maternity triage.
Must Do
The Princess Alexandra Hospital
The trust should consider streaming patients effectively to reduce the demand on the service.
Should Do
St Mary's Hospital
The trust should continue to ensure all women who present at triage are assessed by a midwife following the triage in maternity guidelines.
Should Do
St Albans City Hospital
The trust should ensure that patients receive treatment within one hour of arrival to the department, in line with national guidance.(Regulation 17).
Should Do
Scarborough Hospital
The service must ensure the service continues to work to improve the following performance standards at Scarborough hospital; the median time from arrival to treatment. the percentage of patients admitted, transferred, or discharged within four hours. the monthly percentage of …
Must Do
Salford Royal Hospital
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access to the service when they need it.
Must Do
Salford Royal Hospital
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access to the service when they need it.
Must Do
Royal Shrewsbury Hospital
The trust must ensure patients can access care and treatment in a timely way. This includes ambulance handover times and patient waiting times for treatment and arrangements to admit, treat and discharge patients.
Must Do
Royal Shrewsbury Hospital
The trust must ensure that all patients are triaged in a timely way.
Must Do
Rochdale Infirmary
The service must ensure it acts to mitigate the risks to patients waiting in the department including those waiting for triage, treatment, admission or on a trolley. It must ensure patients can access to the service when they need it.
Must Do
Pilgrim Hospital
The trust should ensure triage is a face to face encounter with a patient for ambulance conveyances.
Should Do
Peterborough City Hospital
The trust should ensure that it continues to improve the waiting times of women and birthing people attending the triage unit.
Should Do
Peterborough City Hospital
The trust should review the triage process around the documentation of women’s admission unto patient records and the transfer of women from day assessment unit to triage.
Should Do
North Manchester General Hospital
The trust must ensure they assess and do all that is reasonably practicable to mitigate risks to women, birthing people and newborns. Regulation 12(1)(2)(a)(b) 1. This includes but is not limited to: • operating effective and timely triage processes to …
Must Do
Northern General Hospital
The trust must improve patient waiting times in the Accident and Emergency department.
Must Do
Montagu Hospital, Mexborough
ThetrustshouldensureUTCsignageinsideandoutsidethebuildingiscorrectanduptodate.
Should Do
Montagu Hospital, Mexborough
Thetrustmustensurethatpatientsareprioritisedbasedonriskorconditionwhenbeingseeninthematernitydayassessmentunitsothatpatientswhopresentwiththehighestrisksareseenfirst.Regulation12(1)(2)(a)(b)
Must Do
Liverpool Walk in Centre
Review the waiting times for patients for initial assessment/triage to treatments. The provider should improve these waiting times so that services are responsive to the needs of children and young people across each of the Walk in Centre locations.
Should Do
Lister Hospital
The service should ensure that patients referred to specialist doctors from the emergency department are seen in a timely manner.
Should Do
Lister Hospital
The trust should ensure that on-call medical teams are able to respond quickly to urgent and emergency referrals.
Should Do
Kidderminster Hospital and Treatment Centre
The needs of patients with minor injuries are included in the new strategy for the urgent care division.
Should Do
Kettering General Hospital
The service should continue to explore how it improves speciality response times in the urgent and emergency care department.
Should Do
Kettering General Hospital
The servicemust ensure people have timely access to services such as first definitive tretament for paediatric services and promptly receive the right treatment in line with national guidance.
Must Do
Kettering General Hospital
The servicemust ensure effective systems are in place and fully implemented to assess and treat patients at risk of sepsis in a timely manner. This includes but is not limited to ensuring antibiotics are administered within 1 hour of suspecting …
Must Do
Kettering General Hospital
The servicemust ensure patients receive timely access to treatment. This includes but is not limited to ensuring waiting times from referral to treatment and arrangements to admit, treat and discharge patients are in line national standards.
Must Do
John Radcliffe Hospital
The trust should consider progressing their plans to introduce a critical care outreach team.
Should Do
Hemel Hempstead General Hospital
The trust should ensure that patients receive treatment within one hour of arrival to the department, in line with national guidance.
Should Do
Hemel Hempstead General Hospital
The trust should continue to ensure people can access the service when they need it.
Should Do
Hemel Hempstead General Hospital
The trust should ensure that patients received antibiotics for the treatment of suspected sepsis in a timely manner.
Should Do
Great Western Hospital
The service must ensure that triage processes are safe, risk assessments are carried out, and women and birthing people have access to parity of service at any time of day or night.
Must Do
Fleetwood Hospital
The trust should consider processes to reduce the number of missed appointments.
Should Do
Fleetwood Hospital
The trust should ensure it improves the ability of patients to access the service when they need it and receive the right care in a timely way.
Should Do
Fleetwood Hospital
The trust should ensure it improves the ability of patients to access the service when they need it and receive the right care in a timely way.
Should Do
Fleetwood Hospital
The trust should ensure that an escalation procedure is in place for paediatric patients waiting more than 15 minutes from time of arrival to initial assessment in line with national standards.
Should Do
Fleetwood Hospital
The trust must ensure it improves the proportion of people waiting less than 62 days from urgent referral to first definitive treatment, in line with operational standards.
Must Do
Fleetwood Hospital
The trust must ensure it improves waiting times for urgent cancer referrals in line with operational standards; particularly for those patients referred with suspected (symptomatic) breast cancer.
Must Do
Ellesmere Port Hospital
The trust should continue to embed the changes made to the triage systems and processes.
Should Do
Doncaster Royal Infirmary
The trust must ensure that patients are prioritised based on risk or condition when being seen in the maternity day assessment unit so that patients who present with the highest risks are seen first.
Must Do
PPO death in custody recommendations(28)
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all staff are fully aware of and understand their responsibilities in a medical emergency, including the use of an emergency response code if a prisoner has chest pains and documenting incidents.
The Governor and the Head of Healthcare
mental health and/or general nurses are called to assess concerns about prisoners’ health and well-being, and
The Governor
The Governor should ensure that when a clinician advises that a prisoner should be sent to hospital: • the policy of referring such decisions to the duty governor is rigorously enforced and; • where the advice is not followed, the …
The Head of Healthcare
The Head of Healthcare should ensure that in a medical emergency, the patient is moved to an appropriate area where they can be fully assessed and treated.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who are unwell and require clinical monitoring are reviewed overnight.
The Head of Healthcare
The Head of Healthcare should ensure there is a robust policy for the delivery and follow up of FIT tests and their results, and that patients who decline to engage are offered a face-to-face appointment with a GP to discuss.
The Governor
The Governor should ensure that control room staff accurately communicate the location of an incident and request an ambulance as soon as an emergency code is radioed.
The Head of Healthcare
The Head of Healthcare should ensure that where there are serious concerns about the health of a prisoner, staff use an emergency code to summon assistance and alert control room staff to call an ambulance immediately, in line with Prison …
The Head of Healthcare
The Head of Healthcare should ensure that: staff know how to escalate if a further on-site clinical assessment is not available at the desired time.
The Head of Healthcare
The Head of Healthcare should ensure that: staff are able to decide if an urgent appointment demands an immediate response;
The Governor
The Governor should ensure that all staff understand their responsibilities during a medical emergency, and in particular that: officers fully understand the expectation that preservation of life must take precedence when considering entering a locked cell whether at night or …
The Head of Healthcare
The Head of Healthcare should ensure that prisoners presenting with chest pain are managed in line with NICE guidelines on the diagnosis of chest pain and, where indicated, referred for emergency treatment.
The Head of Healthcare
The Head of Healthcare should ensure that there is: • Adequate training for nurses responsible for assessing the clinical condition and appropriate treatment pathways for prisoners, and • At least one nurse trained in advanced clinical assessment skills during all …
The Head of Healthcare
The Head of Healthcare should address the high number of “Code Calls” by: • Introducing an “Urgent Assessment” system whereby a prison officer can request a same day assessment to be undertaken by a Registered Nurse; and • Implementing an …
The Head of Healthcare
The Head of Healthcare should ensure that: • the welfare check sheet used for monitoring prisoners suspected to be under the influence of a substance includes timescales for review, escalation and transfer to hospital; and that • training is provided …
The Head of Healthcare
The Head of Healthcare should ensure that staff are aware of the Multi-Professional Complex Case Clinic (MPCCC) criteria and consider its early use for a patient who is deteriorating.
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a MUST assessment when a person is weighed and ensure any concerns are escalated with immediate effect.
The Head of Healthcare
The Head of Healthcare should ensure that when patients are presenting with red flag symptoms an urgent chest X-ray is ordered under the 2-week guidelines and in accordance with NICE Guidelines NG12 suspected cancer: recognition and referral.
The Head of Healthcare
The Head of Healthcare should ensure that there is a robust process in place for the review of healthcare applications to ensure a timely review by the most appropriate member of the healthcare team.
The Approved Premises Manager
ensure that staff err on the side of caution and call an ambulance immediately when a resident is found unresponsive and may have taken drugs;
The Head of Healthcare
The Head of Healthcare should ensure that, once an emergency code blue has been called and an ambulance is on the way, staff should only stand it down if they are confident that the patient has fully recovered.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should formalise the way that PS incidents are assessed and the handover of care from healthcare to prison staff including: • The development and introduction of a PS assessment template for SystmOne, to include …
The Head of Healthcare
The Head of Healthcare should ensure that all staff receive appropriate training in differential diagnosis pathways, and all pathways are considered when attending an emergency response.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a suitable location where a prisoner can receive short-term 24-hour nursing care if required.
The Head of Healthcare
The Head of Healthcare should ensure that there is always a registered nurse or a GP present during a medical emergency. Guidance on the role of GPs and senior managers during an emergency should be developed, detailing guidance on leadership, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare staff have entry to prisoner’s cells on K Wing at the weekend, to allow face to face clinical assessments when required.
The Head of Healthcare
The Head of Healthcare should review the use of the NHS 111 service to determine whether there is a need to extend the provision of prison GPs.
NHS England and SECAmb
NHS England and SECAmb should conduct an investigation into the circumstances surrounding Mr Dawes-Clarke’s resuscitation, including the actions of paramedics in attendance.
IOPC learning recommendations(13)
Recommendations - Gwent Police, February 2021
The IOPC recommends that Gwent Police engages with external agencies, who regularly request the police to conduct welfare checks on their behalf, and establishes a Memorandum of Understanding. This is to ensure that both the agencies and Gwent Police are …
Recommendations - Gwent Police, February 2021
The IOPC recommends that Gwent Police creates a detailed question set for call handlers responding to requests from external agencies to conduct welfare checks. The prompts should help call handlers to elecit key information during a conversation to help inform …
Investigation into police contact with a man following a report into his …
The IOPC recommends that Merseyside Police ensures that there is a robust agreement in place between the force and North West Ambulance Service NHS Trust in relation to people who come into contact with the police and require urgent medical …
Recommendations - Sussex Police, March 2020
If such a situation arises, a review should take place after proactive measures to allocate responsibility have been taken, as opposed to at the material time of the patient being absent in order to avoid delay in resourcing a response. …
Recommendations - Nottinghamshire Police, January 2021
The IOPC recommends that Nottinghamshire Police provide training to ensure that control room operatives ensure that the Threat, Harm, Risk, Investigation, Vulnerability, Engagement (THRIVE) risk assessment is appropriately endorsed on all SAFE incident logs. A review of a number of …
Recommendations - Nottinghamshire Police, January 2021
The IOPC recommends that Nottinghamshire Police provides guidance for their control room operatives so that they are clearly aware of the minimum set of standards which highlight the information should be included in SAFE incident logs for individuals suffering from …
Recommendation - North Yorkshire Police, August 2023
The IOPC recommends that North Yorkshire Police should take steps to satisfy itself that, in line with Authorised Professional Practice, officers and members of police staff understand how to identify the signs that a person is drunk and incapable. Such …
Recommendations - Northumbria Police, July 2024
The IOPC recommends that Northumbria Police should work with Cumbria, Northumbria Tyne and Wear NHS (CNTW) to review and revise the referral points discussed in the Street Triage Team (STT) Operational Policy document around when a member of the public …
Recommendations - Sussex Police, March 2020
The Sussex Police and Sussex NHS Partnerships should also review the ‘Missing Persons Police – Appendix E – Absent Without Leave (AWOL)’ with a view to establishing which agency is responsible for conducting checks to ascertain the wellbeing and whereabouts …
Recommendations - Sussex Police, November 2023
The IOPC recommends that Sussex Police develop an escalation process to be adopted in the event that a call has been passed to the Ambulance Service but the Ambulance Service is unable to resource the call. This process should be …
Recommendation – Greater Manchester Police, November 2023
The IOPC recommends that Greater Manchester Police implements essential changes to ensure the Greater Manchester Mental Health Tactical Advice Service (MHTAS) are being utilised by response officers and call handlers during mental health incidents. These changes should include: Amending the …
Police contact with man prior to his death - Lancashire Constabulary, June …
The IOPC recommends that Greater Manchester Police (GMP) and Lancashire Constabulary should create a joint protocol on how to manage cross-border Grade 1 immediate and Grade 2 priority incidents. This follows an IOPC investigation where there were concerns for a …
Recommendation - Cambridgeshire Constabulary, May 2024
The IOPC recommends that Cambridgeshire Constabulary liaises with the local authority to request access to any resource list they may have regarding organisations that can provide transport for individuals who use a wheelchair of any size. The force should ensure …
PHSO ombudsman recommendations(1)
IMB annual reports(4)
Heathrow and City airports Short Term Holding Facilities (2021)
The reporting period was significantly impacted by the Covid-19 pandemic, leading to concerns about infection control, longer detainee stays, and increased waiting times. Key issues included slow implementation of effective Covid-19 measures, inability for detainees to access personal medication, and inadequate hygiene and family facilities in some terminals. Despite these challenges, Detention Custody Officers were observed to be largely kind and courteous.
PRISON
Key concerns
Haverigg (2024)
HMP Haverigg, a Category D open prison for men, maintained low levels of self-harm and violence, with two deaths in custody. The Board commended efforts to improve facilities and provide high-standard healthcare for an increasingly elderly and complex population, despite some staff vacancies. Key concerns included challenges for ex-PCoSO prisoners in finding employment, difficulties securing accommodation on release, and prisoners' reluctance to raise complaints due to perceived negative consequences.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2024)
The IMB's annual report for Kent Coast STHF (Kent Intake Unit, Western Jet Foil, Manston, and Frontier House) highlights continuous operations processing a high volume of arrivals. While commending staff's empathetic approach and noting no self-harm or assault incidents, the Board raises significant concerns about privacy during interviews, inadequate isolation facilities, and insufficient information provided to detainees about their onward journey. It recommends improvements in communication, facility maintenance, and welfare provision for unaccompanied children.
PRISON
Key concerns
Derwentside (2024)
The IMB report for Derwentside IRC highlights a generally safe environment and positive staff interactions despite significant staff churn and the planned re-roling of the centre. However, key concerns persist regarding the centre's remote location and poor communications infrastructure, contributing to inhumane treatment via long, disruptive journeys for detainees. While healthcare provision is praised, unacceptably long waits for Rule 35(3) assessments and reduced activity provision for wellbeing remain critical issues, alongside ongoing dissatisfaction with food and the lack of a detention time limit.
PRISON
Key concerns
Health investigations(65)
Independent investigation: Warren Duke, Slough (but Tees patient) (2015) — Rec Recommendation 6
TEWV must take action Trust wide to ensure that any referral made to an external or internal service indicates clearly the level of urgency.
north_east_yorkshire
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020) — Rec 7
This investigation fully supports the recommendation from the EPUT investigation that the Trust should ensure all failed urgent home visits are communicated to a team leader or equivalent to agree an appropriate plan of action including, if necessary, the use of out of hours services.
east_of_england
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 3
West Hertfordshire Hospitals NHS Trust and Hertfordshire Partnership NHS Foundation Trust should develop joint protocols that clearly detail action that should be taken, and what the response from both services should be, when there are concerns about the mental health or behaviour of an individual on the premises at AAU …
east_of_england
Independent investigation: Robert CrookElsie Crook, Swindon (2007) — Rec Three
In conjunction with NHS Swindon the Trust must review the newly revised Single Point of Entry system including the changes to Standard Operating Procedures within a twelve-month period of its inception.
south_west
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 9
The Devon Partnership NHS Trust must ensure that there are clear care pathways within and between mental health services. This should be based on: clear operational policies for each service; unambiguous acceptance criteria for referrals which make it absolutely clear who the service is for; a named manager within the …
south_west
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 2
Care Pathway between START and HTT – It is recommended that a protocol be developed to clarify the care pathway between START and the HTT. This protocol should make it clear what action is to be taken by whom when a person is referred on to the HTT. Secondly the …
london
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 1
Review of the ERC/START – It is recommended that the review should look at the way in which referrals are being made and managed by the Trust to ensure that all referrals are appropriately screened, assessed and sign posted on to the correct service. If a referral is to be …
london
Independent investigation: Jonathan Palgrave, Preston (2018) — Rec 1
The Trust must review the current pathways in CCTTs to determine if the identified needs of patients who meet the threshold for an assertive outreach approach are being met.
north_west
Independent investigation: Jane WheatleyGary Gardiner, Sheffield (2007) — Rec 1
The Trust should ensure that when urgent requests are made for initial appointments these are dealt with in line with the acute care pathway and this should be the subject of audit on a regular basis.
north_east_yorkshire
Independent investigation: Caroline Evans, Llangadog, Camarthen (2003) — Rec 8.4.21
Carmarthenshire Local Health Board and Pembrokeshire & Derwen NHS Trust to have clear protocols and guidelines in place for access to general medical services out of hours.
wales
William Mead – Root Cause Analysis Investigation Report — Rec e)
That SWASFT instigates a plan to train call advisors in probing questions, recognition of complex calls and referrals to clinicians.
south_west
William Mead – Root Cause Analysis Investigation Report — Rec d)
That the SW develops existing plans for referral to assess models of care between primary and secondary care.
south_west
William Mead – Root Cause Analysis Investigation Report — Rec c)
That NHS England South escalates the issues regarding the need for more defined standards regarding how 111 services and local OOH services interact in regard to dispositions.
south_west
William Mead – Root Cause Analysis Investigation Report — Rec b)
That NHS England South escalates the issues regarding the sensitivity of NHS 111 Pathways.
south_west
*Mental health homicide investigation legacy report into the care and … — Rec Recommendation Five
The Trust will conduct an audit in conjunction with Primary Care stakeholders to ascertain the timeliness of referral processes. This audit to be completed within six months of the publication of this report. The Trust will ensure that referral pathways are revised if necessary in the light of the audit …
Mr X This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust
south_east
Assurance Review: Trust recommendations — Rec 43
Emergency theatre access • The Trust should monitor the use of emergency theatres out of hours in Urology (building on the analysis provided in this report) to establish whether the existing Standard Operating Procedure (Theatre Access) is effective in changing the pattern of practice highlighted by this report. • This …
north_west
Assurance Review: Trust recommendations — Rec 22
Improving the pathway for bladder cancer diagnosis • Where appropriate, conducting a flexible cystoscopy on the day of attending the One Stop Clinic would make this a truly one-stop service. • Patients meeting the two-week wait criteria with visible haematuria and normal estimated glomerular filtration rate (eGFR) should be triaged …
north_west
An independent investigation into the care and treatment of Mr … — Rec 4
Trusts and commissioners should be clear about the need for a joint approach between acute and mental health trusts of the joint management of A&E referrals, to include: Systems to expedite the referral in the shortest possible time, mindful of the 4-hour response target required of A&E, for which A&E …
east_of_england
An independent investigation into the care and treatment of Mr … — Rec 1
The Trust must review the current pathways in CCTTs to determine if the identified needs of patients who meet the threshold for an assertive outreach approach are being met.
Mr H. At the time of the incident Mr H was receiving care from Lancashire and South Cumbria NHS Foundation Trust
north_west
Independent investigation report into the care and treatment of Mr … — Rec 6
NHS Derby & Derbyshire CCG must provide assurance that there are arrangements in place to access PICU beds in urgent situation, including an escalation protocol with timescales and stepping up process agreed.
midlands
Accepted
Independent investigation into the care and treatment of Ms A — Rec 17
The Trust should review the route undertaken by acutely mentally unwell patients, who are admitted via the MHLS to Oxleas House.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent Assurance Review – Mr X — Rec 4
The Trust and the Commissioning bodies should consider what arrangements, involving primary and secondary services may be put in place to ensure effective pathways for rapid clinical review for those patients whose clinical profile, including risk, indicates the need for this.
london
Independent investigation report into the care and treatment of Yusuf — Rec 4
There was a lack of clarity in primary care about accessing the opinion of paediatric services at Rotherham Hospital. To avoid future ambiguity, a written protocol should be produced for the agreed pathway and criteria for referring on for further paediatric assessment from primary care. This should include: the role …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020) — Rec 3
EPUT should undertake an audit of referrals within services for working age adults to explore the current time periods from receipt of the referral to providing a service which addresses the concerns of the referrer. This audit should include referrals both from colleagues in secondary care and primary care.
east_of_england
Independent investigation: Valerie Donnelly, Preston (2011) — Rec R1
The trust should ensure that all calls to any out-of-hours phone services and helplines are risk assessed to see whether any immediate action needs to take place.
north_west
Independent investigation: Sarah Smart, Oxford (2005) — Rec 15.7
The panel recognises that in working cases like Mr S, who do not necessarily meet Crisis Resolution and Home Treatment criteria but do need urgent responses, there is a need for CMHTs and other teams to work effectively in transferring patient care across team interfaces. Where there is disagreement between …
south_east
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 11
Hertfordshire Partnership NHS Foundation Trust should ensure that clear pathways for the use of medication in the AAU and Accident and Emergency department settings are developed. These should include risk assessment of medication use in all patients including those with medical co-morbidity.
east_of_england
Independent investigation: Robert CrookElsie Crook, Swindon (2007) — Rec One
The Trust should undertake a comprehensive audit six months after the publication of this report/one year on from the implementation of the new revised Priority Pathways (whichever is first). This audit should be developed in conjunction with local stakeholders. As well as auditing adherence to policy and procedure it should …
south_west
Independent investigation: Rae Torbet(Ms E), Hastings, Sussex (2003) — Rec 9.3.5
that the Trust should consider whether A&E liaison service should be part of an integrated crisis service.
south_east
Independent investigation: Pauline StephenHanane Parry, Aintree Merseyside (2003) — Rec 6
A system for quickly flagging and updating risk information on psychiatric patients under community care, and assessed as emergency cases in A&E, should be developed and deployed4.
north_west
Independent investigation: Pauline StephenHanane Parry, Aintree Merseyside (2003) — Rec 5
A liaison psychiatric referral policy or care pathway for use by A&E medical staff should be developed4.
north_west
Independent investigation: Julie McKinley, Finsbury Park (2009) — Rec 7
Referral to Haringey Advisory Group on Alcohol (HAGA) – It is recommended that a clear pathway between the Trust and HAGA should be agreed for those persons who have a dual diagnosis (mental disorder and alcohol problems. The pathway must address the issue as to what action will be taken …
london
Independent investigation: John TaylorBeverley Taylor, Skipton (2021) — Rec 7
There were delays in referring Patient E to IHTT because of barriers to effective communication between the GP and FRS. The first urgent referral from the GP was not responded to appropriately. • The Trust should develop a standard operating procedure (SOP) for urgent referrals from primary care. This should …
north_east_yorkshire
Independent investigation: Harry Upton, Culcheth, Warrington (2002) — Rec 9.1
The Trust should consider the delivery of a more responsive CAMH Service to patient’s such as DC. The RCA team recommends that a review is conducted by the Trust of the demands and resources within CAMHS to ensure they are meeting the requirements of service users and other clinicians. In …
north_west
Mental health homicide investigation legacy report into the care and … — Rec 9
The Trust will ensure that all Community Mental Health Teams are instructed of the referral routes to the Crisis and Home Treatment Team and of the role that Duty Workers have in managing patients who require urgent assessment or intervention. The Trust will ensure that all Service Users on Community …
south_west
Accepted
Independent investigation into the care and treatment of P in … — Rec 1
The Trust should complete its review of Rehabilitation Services within 3 months of the publication of this report, and be able to demonstrate a clear plan, agreed by commissioners, for providing increased local capacity based upon current needs assessment.
Hertfordshire Partnership University NHS Foundation Trust
east_of_england
Independent investigation into the care and treatment of Mr D … — Rec 5
The Crisis Resolution and Home Treatment Team (CRHTT) should review its admission process to ensure urgent referrals can be accepted and managed during handover periods.
Cambridgeshire and Peterborough NHS Foundation Trust
east_of_england
Assurance Review: Trust recommendations — Rec 25
Nephrostomy service • The Trust and Clinical Commissioning Groups (CCGs) should review arrangements for out-of-hours nephrostomy provision, including over bank holidays and emergency cover. • The arrangements that have been put in place should be assessed to ensure that standards for accessing nephrostomy provision out of hours and for returning …
north_west
An independent investigation into the care and treatment of mental … — Rec 6
NHS Manchester CCG should assure themselves that the Trust is identifying the cohort of patients at most risk of disengagement from services, who have complex needs and often forensic histories with a background of drug abuse. This identification should then lead to the Trust being able to provide an assertive …
Greater Manchester Mental Health NHS Foundation Trust
north_west
Partially Accepted
An independent investigation into the care and treatment of Adult … — Rec Recommendation 4
MHA and urgent requests for assessment The family was left unsupported and without access to mental health support services over a weekend. There was an over-reliance on emergency services responding if a crisis occurred before the planned assessment. The Trust must ensure that urgent requests for assessment are considered and …
south_west
An assessment of a mental health trust’s internal investigation of … — Rec R3
The Trust should establish a clear and accessible Single Point of Access (SPA) service for adult mental health referrals, ensuring a ‘no wrong door’ approach and timely access to appropriate care and treatment pathways, including forensic and personality disorder services. This should include clear criteria for RAG rating and prioritisation …
north_east_yorkshire
Investigation Report into the NHS Care provided to the late … — Rec 6.4
The urgent care system as a whole should explore ways to ensure that when patients present to different organisations, information is more effectively shared.
south_east
Independent investigation report into the care and treatment of Mr … — Rec 4
DHCFT should ensure that the management of requests for inpatient admission in DHCFT should incorporate escalation actions to take place in cases where there is the likelihood of a patient requiring detention under the MHA, and is in need of a Derbyshire placement urgently.
midlands
Accepted
Independent investigation into the care and treatment of Mr DB: … — Rec 10
Pennine Care NHS Foundation Trust & Stockport Metropolitan Borough Council : should have triggers for responding to crisis calls and an escalation process in place
Mr DB . At the time of homicide December 2014 Mr DB was receiving care and treatment from Pennine Care NHS Foundation Trust
north_west
*Independent investigation into the care and treatment of Mr A: … — Rec 3
West Hertfordshire Hospitals NHS Trust and Hertfordshire Partnership NHS Foundation Trust should develop joint protocols that clearly detail action that should be taken, and what the response from both services should be, when there are concerns about the mental health or behaviour of an individual on the premises at AAU …
Hertfordshire Partnership NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of a … — Rec 4
The Trust must provide clarity about protocols and responsibilities with respect to responding to increased need for interventions, zoning, and the process for considering and effecting inpatient admissions from the community.
east_of_england
Independent investigation report into the care and treatment of Yusuf — Rec 1
Difficult conversations took place between relatives and hospital staff as Yusuf’s family attempted to access urgent care. • All clinical teams are to be encouraged to attend simulation communication training on conflict in patient care. • It is advised that a reminder be given to staff about responding to parent …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation report into the care and treatment of Yusuf — Rec 1
At times there was conflict between relatives, paramedic teams and hospital staff while Yusuf’s family attempted to access urgent care. National research should be commissioned to look into why and when parents raise concerns about their children’s acute presentation to health services. There is a need for the development of …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Stefan Welch, Brighton (2010) — Rec 4
The Trust will conduct an audit in conjunction with Primary Care stakeholders to ascertain the timeliness of referral processes. This audit will be completed within six months of the publication of this report. The Trust will ensure that referral pathways are revised if necessary in the light of the audit …
south_east
Independent investigation: Simon Sutton, Birkenhead (2007) — Rec R5
The trust should assure itself that patients are treated and managed in a holistic way and are referred to appropriate services. We recommend that the trust conducts audits (annually at a minimum) to review patient pathways from referral to discharge.
north_west
Scottish Fatal Accident Inquiries(3)
Stuart Robert Hamilton
It is recommended that the instructions to ambulance crews to take all casualties to the Garrick Hospital be reconsidered and that consideration be given to establishing a protocol dealing with the circumstances in which a patient should be taken direct to a hospital other than the Garrick.
Jun 2002
Gordon Scott Niven
I accordingly recommend that the issue should be addressed as a matter of priority by those bodies having professional interest, in particular The Faculty of Accident and Emergency Medicine and the Society of British Neurological Surgeons.
Mar 1999
Niamh Frances Bysouth/Lafferty and Terrie Faye Oliver also known as Georgia May Rowe
When young people such as Niamh attend Accident and Emergency departments of hospitals in Scotland presenting with histories suggesting serious self-harm, or suggestive of a suicide attempt there must be value in having a psychiatric/psychological assessment carried out as near to the time of presentation as possible. At present, that option is not available automatically. Consideration should be given to …
Apr 2012
Independent reviews(10)
Mental Health Taskforce 2016 — Rec 18
By 2020/21, NHS England should invest to ensure that no acute hospital is without all-age mental health liaison services in emergency departments and inpatient wards, and at least 50 per cent of acute hospitals are meeting the ‘core 24’ service standard as a minimum.
Health & Social Care
Mental Health Taskforce 2016 — Rec 17
By 2020/21, NHS England should ensure that a 24/7 community-based mental health crisis response is available in all areas across England and that services are adequately resourced to offer intensive home treatment as an alternative to an acute inpatient admission. For adults, NHS England should invest to expand Crisis Resolution …
Health & Social Care
Angiolini Review — Rec 28
There should be clear procedures around the operation of section 136 from initial point of contact, including joint protocols between police, local health services and voluntary sector organisations. Health-based ‘places of safety’ should not be permitted to exclude those who are intoxicated or showing signs of agitated/aggressive/disturbed behaviour.
Policing & Security
Accepted
Angiolini Review — Rec 27
There should be proper resourcing of national healthcare facilities to accommodate and respond to vulnerable people in urgent physical and/or mental health need coming into contact with the police.
Policing & Security
Accepted
Angiolini Review — Rec 6
The restraint of anyone suffering a mental health crisis should be identified in national policy and training as a high risk strategy giving rise to a medical emergency. Where all else has failed or life threatening circumstances demand, it should be used for the very shortest time possible and an …
Policing & Security
Accepted
Angiolini Review — Rec 24
The use of police vehicles for transporting people detained under section 136 should be stopped in all but the most exceptional of situations. These are health emergencies (particularly where force has been used) and an ambulance should be summoned for all section 136 detainees.
Policing & Security
Accepted
Angiolini Review — Rec 23
Joint local protocols should be established between police forces, ambulance services and hospitals to ensure appropriate medical care for intoxicated people in the appropriate environment.
Policing & Security
Accepted
Angiolini Review — Rec 22
The Government should give consideration to the viability and cost-effectiveness of drying out centres, and consider piloting a centre or centres in large urban areas where it is most likely to be cost-effective, and linking such centres to existing A&E departments. An alternative would be the fundamental redesign of A&E …
Policing & Security
Accepted
Angiolini Review — Rec 21
An NHS initiative at the national level should examine whether to prohibit the refusal of access to A&E or to health-based places of safety under section 136 Mental Health Act 1983 (section 136) on the basis of intoxication. It should also consider the redesign of A&E facilities to allow for …
Policing & Security
Accepted
Darzi Review — Rec 8
A&E is in an awful state. There are three types of A&E department. Type 1 are what most people think of as A&E — they are major departments and able to deal with the full range of emergencies. Type 2 are for specific conditions such as dental or ophthalmology and …
Health & Social Care
PHSO casework decisions(1)
Domestic Homicide Reviews(40)
West Berkshire — recommendation 2
Another level of triage should be considered to ensure that not all calls are processed and passed through to CHRTT; some should be diverted to either social care or non-health services.
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
St Helens — recommendation 22
Review advice/pathways in place relating to alcohol related attendances/admissions
St Helens and Knowsley Teaching Hospitals …
South Gloucestershire — recommendation 17
Workflow timescales between triage and assessment to be established
Developing Health and Independence
Norfolk — recommendation IMR_NFR_8
Review responses to urgent situations with system partners. Review the information given by the Support Worker in this case to establish whether enough detail was provided to triage appropriately, whether staff require guidance when making referrals or whether changes are needed in the processes followed by staff triaging referrals and …
Norfolk First Response
Norfolk County Council
Western Suffolk — recommendation 1
Any existing protocol that exists between GPs and The Trust for emergency referrals be reviewed and clarity communicated about expectations.
Norfolk and Suffolk Foundation Trust | …
Norfolk and Suffolk NHS …
Lancaster — recommendation 6
To understand the capacity of urgent referrals and the use of telephone triage
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Peterborough — recommendation 1
A single referral pathway to MARAC must be agreed, implemented and monitored as soon as possible
Safer Peterborough Partnership
Ealing — recommendation 23
Implement clinical domestic violence enquiry within the triage system for the urgent care centre.
Ealing Hospital NHS Trust
Ealing Hospital NHS Trust
Ealing — recommendation 22
Explore options of commissioning independent domestic violence advocacy service provision to be located with the urgent care centre.
Ealing Hospital NHS Trust
Ealing Hospital NHS Trust
Hammersmith and Fulham — recommendation IC2
All new psycho-social assessments, or those carried out in the Emergency Department, whether by psychiatry or triage, especially where a person has a history of domestic abuse (whether as victim / survivor or alleged perpetrator) should include an overview of where the person is staying, who is there with them …
Imperial College Healthcare NHS Trust
Imperial College Healthcare NHS …
Sheffield — recommendation 5
NHS Sheffield and future commissioners of NHS services, should ensure that in their directory of services for the implementation of 111, it identifies the disposition for a mental health crisis to an appropriate emergency / urgent care service.
NHS Sheffield | future commissioners of …
Sheffield Trust
Sheffield — recommendation 4
NHS Sheffield and future commissioners of NHS services, should ensure any signposting directs contacts regarding a mental health crisis to appropriate emergency / urgent care services.
NHS Sheffield | future commissioners of …
Sheffield Trust
West Cumbria — recommendation North Cumbria Integr
To complete a review to be completed of current pathway and follow up for patients who leave A&E prior to completing treatment.
North Cumbria Integrated Care NHS Foundation …
North Cumbria Integrated Care …
Lincoln — recommendation i)
A monthly audit is undertaken of all safeguarding referrals completed by LCHS Urgent Treatment Centre staff to ensure all safeguarding procedures have been followed.
Lincolnshire Community Health Services
Lincolnshire Community Health Service …
Swindon — recommendation 11
Mental Health Services to develop clear pathways to support 111 advisors and clinicians to gain advice and support regarding possible referrals to Mental Health Services and enable appropriate direct referrals without service users in crisis having to go back to the their GP.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Swindon — recommendation 5
For all members of the Swindon Intensive Team to be aware of patients who have a rapid access plan into services and to be aware of its purpose.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Nuneaton and Bedworth — recommendation 24
George Eliot Hospital to either explore the possibility of an IDVA being based on site, or to put in place a procedure by which A & E staff can contact the on call IDVA.
George Eliot Hospital
George Eliot Hospital
Nuneaton and Bedworth — recommendation 21
George Eliot Hospital targets front line staff in A&E with specific domestic abuse training to enable them to identify people at risk and initiate appropriate supportive and preventative actions.
George Eliot Hospital
George Eliot Hospital
Somerset — recommendation 6
Change how Patient Liaison Team (with A&E) follow up to patients referred to the PLT but leave the hospital without being seen
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Somerset — recommendation 2
Improve knowledge of domestic abuse awareness in Emergency Department
Somerset NHS Foundation Trust
Taunton and Somerset NHS …
Nottingham — recommendation 11.2
Agencies should consider whether individuals dealing with multiple disadvantages can be offered “open appointments” where it is safe to do so. Experience shows that services can then be reactive when individuals require input, particularly at a point of crisis.
All Agencies
Lincoln — recommendation 6
The Safer Lincolnshire Partnership should ask the Domestic Abuse Core Priority Group to consider the development of a Domestic Abuse pathway for East Midlands Ambulance Service in Lincolnshire. East Midlands Ambulance Service already have this in place in other Local Authority areas.
Safer Lincolnshire Partnership | East Midlands …
Lincolnshire Partnership NHS Foundation …
Guildford — recommendation 5.47(e)
ensure that frequent attendees at the Emergency Department are identified as being at high risk to enable appropriate safeguarding procedures to be considered and implemented.
Frimley Park Hospital NHS Foundation Trust
Frimley Health NHS Foundation …
Lancaster — recommendation 5
To review the interface with CRHT re referrals for urgent assessments.
Lancashire Care NHS Foundation Trust
Lancashire and South Cumbria …
Birmingham — recommendation GP Practice Recommen
A more robust referral process and threshold for referral to be agreed with secondary health services to ensure that patients receive prompt initial assessment and appropriate treatment.
GP Practice
Ealing — recommendation 21
Identify and audit DV attendances in the urgent care centre to establish if cases have been managed appropriately, including if they have been provided with information and advice and if the case has been subject to a domestic violence risk assessment.
Ealing Hospital NHS Trust
Ealing Hospital NHS Trust
Leicester — recommendation 7
It is recommended that there is a review of the systems and processes of the medical provision in outpatients, to deliver a service which provides appointments to patients when required. This process should commence within two months and report through the performance management systems to the Board of Directors.
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Cornwall — recommendation 21.6.1
Mental Health services to develop an integrated emergency referral pathway and ensure that this is reflected consistently across all policy, process and practice.
Cornwall Foundation Trust | Royal Cornwall …
Royal Cornwall Hospital
Northumberland — recommendation 9
To consider use of an ‘alert’ system, as recommended in NHCFT’s IMR, to identify patients with complex needs who are frequent attenders to A&E. This is in order to facilitate access to specialist support services and prompt, where necessary, Safeguarding referrals.
Newcastle upon Tyne Hospitals NHS Foundation …
THE NEWCASTLE UPON TYNE …
Northumberland — recommendation 5
To incorporate into the recommended alert system a prompt for Safeguarding referrals, where necessary, in relation to frequent attenders.
Northumbria Healthcare NHS Foundation Trust
NORTHUMBRIA HEALTHCARE NHS FOUNDATION …
West Cumbria — recommendation North Cumbria Integr
to continue to improve awareness and responses to domestic abuse through the A&E and Domestic Abuse Improvement Plan, to include increased use of DASH and MARAC referrals and the ‘think family’ Screening tool
North Cumbria Integrated Care NHS Foundation …
North Cumbria Integrated Care …
Gloucestershire — recommendation Q
Ensure mechanism by which urgent concerns can be shared between Primary Care and Mental Health teams.
NHS Gloucestershire
Gloucestershire Hospitals NHS Foundation …
Dudley — recommendation Adult Social Care 1
72hr post discharge review to be carried out for all urgent care referrals, to ensure any changes in need or identification of aids and adaptations are confirmed in a timely manner.
Dudley Council Adult Social Care
Swindon — recommendation 17
111 Care UK leads to continue to contribute to discussions at a CCG level regarding the availability of mental health services
CARE UK
Care UK
St Helens — recommendation 24
Review advice/pathways in place relating to substance misuse issues
St Helens and Knowsley Teaching Hospitals …
St Helens — recommendation 23
Review advice/pathways in place relating to bereavement issues
St Helens and Knowsley Teaching Hospitals …
Somerset — recommendation 7.6.1
To consider nationally whether MARAC victims can be added to the exemptions for immediate referrals to and acceptance by mental health crisis teams instead of insisting upon a GP referral.
NHS England
NHS England
Harrow — recommendation 9
Work with commissioners and other strategic and operational partners to ensure the widest possible access to our service and clarity and consistency of referral routes, especially where co-located specialist posts are placed.
Advance
Middlesbrough — recommendation 19.16
GPs to input into the frequent attenders at Emergency Departments.
South Tees Clinical Commissioning Group
Sheffield — recommendation 4.1.4
That the Domestic Abuse Strategic Board should ensure that the pathway development work identified in the recent Domestic Abuse Strategic Review is progressed. The pathway development work should be complete by April 2013 and the work to endorse and critically assess the whole pathway by relevant organisations and partnerships should …
Domestic Abuse Strategic Board
CQC enforcement actions(26)
Conditions Imposed: University Hospitals Birmingham NHS Foundation Trust
The Care Quality Commission placed conditions on University Hospitals Birmingham NHS Foundation Trust's registration. This action followed inspections where the trust had not met the requirements of a previous warning notice and further issues were identified. Conditions were also imposed …
Feb 2024
Conditions Imposed: Mid and South Essex NHS Foundation Trust
The Care Quality Commission (CQC) placed conditions on Basildon University Hospital's registration, requiring leaders to act immediately on urgent safety concerns and provide regular updates on improvements. This action followed inspections between December 2024 and March 2025, which found serious …
Basildon University Hospital
Oct 2025
Conditions Imposed: Mid and South Essex NHS Foundation Trust
The Care Quality Commission (CQC) placed conditions on Basildon University Hospital’s registration following inspections of its medical care and urgent and emergency services between December 2024 and March 2025. CQC found serious overcrowding in the emergency department, risking people’s safety, …
Basildon University Hospital
Oct 2025
Warning Notice: Barts Health NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Barts Health NHS Trust following an inspection of Whipps Cross University Hospital's urgent and emergency services in July. CQC found people experienced very long waits in the emergency department, leading …
Whipps Cross University Hospital
Dec 2024
Fixed Penalty Notice: Shrewsbury and Telford Hospitals NHS Trust
The Care Quality Commission (CQC) issued a fixed penalty notice to Shrewsbury and Telford Hospitals NHS Trust, fining it £4,000. This was for not triaging patients within 15 minutes of attending the emergency department and not ensuring follow-ups for children …
Oct 2020
Conditions Imposed: Portsmouth Hospitals NHS Trust
The Care Quality Commission (CQC) placed four conditions on Portsmouth Hospitals NHS Trust's registration following an inspection of its urgent and emergency department. Inspectors found the emergency department at the Queen Alexandra Hospital was over-crowded with patients not being assessed …
Portsmouth
Jun 2016
Conditions Imposed: Liverpool University Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) imposed conditions on Liverpool University Hospitals NHS Foundation Trust's registration under Section 31 of the Health and Social Care Act 2008. This action was taken due to significant concerns identified during an inspection, including issues …
Oct 2021
Warning Notice: University Hospitals Plymouth NHS Trust
The Care Quality Commission (CQC) issued University Hospitals Plymouth NHS Trust with a warning notice following an inspection of Derriford Hospital's urgent and emergency care department in March. CQC found that the trust must make significant and immediate improvements, outlining …
Derriford Hospital's urgent and emergency care de…
May 2021
Warning Notice: Mid Essex Hospital Services NHS Trust
The Care Quality Commission has issued a warning notice to Mid Essex Hospital Services NHS Trust. This action was taken after concerns were raised around the flow of patients through the A&E department, whether care was being provided soon enough, …
Broomfield Hospital at Chelmsford
Aug 2015
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission has formally warned Medway NHS Foundation Trust that it needs to improve the care it provides to patients in the emergency department at Medway Maritime Hospital, Gillingham. CQC issued warning notices to the trust after an …
Medway Maritime Hospital, Gillingham
Mar 2014
Warning Notice: Brighton and Sussex University Hospitals NHS Trust
The Care Quality Commission told Brighton and Sussex University Hospitals NHS Trust that it must make significant improvements to its Urgent and Emergency Services, specifically concerning the Emergency Department at Royal Sussex County Hospital. Following an inspection on 22 June, …
Royal Sussex County Hospital at Brighton
Oct 2015
Conditions Imposed: The Dudley Group NHS Foundation Trust
The Care Quality Commission varied conditions on The Dudley Group NHS Foundation Trust's registration following an inspection at Russells Hall Hospital. Inspectors found concerns regarding the triage, assessment, and tracking of patients in the emergency department, especially concerning suspected sepsis. …
Russells Hall Hospital
Sep 2018
Warning Notice: Medway NHS Foundation Trust
The Care Quality Commission rated Medway NHS Foundation Trust as Inadequate and recommended it remain in special measures. Following an inspection, CQC told the trust it must make improvements in 31 areas, including patient flow, environment within the emergency department, …
Jan 2016
Warning Notice: North Middlesex University Hospital NHS Trust
Following an unannounced inspection in April, CQC inspectors issued a Warning Notice to North Middlesex University Hospital NHS Trust. This required the trust to significantly improve the treatment of patients attending the emergency department. Inspectors found significant delays in patient …
Jul 2016
Conditions Imposed: Portsmouth Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) placed four conditions on the registration of Portsmouth Hospitals NHS Trust following an inspection of emergency services at Queen Alexandra Hospital. CQC found that too many people were waiting too long for attention in the …
Queen Alexandra Hospital, Portsmouth
Apr 2016
Conditions Imposed: United Lincolnshire Hospitals NHS Trust
The Care Quality Commission (CQC) undertook focused inspections of the emergency departments at Pilgrim Hospital and Lincoln County Hospital on 6 and 7 January 2020, prompted by patient safety concerns. Following these inspections, CQC imposed conditions on United Lincolnshire Hospitals …
Pilgrim Hospital
Feb 2020
Urgent Enforcement Action: North Cumbria Integrated Care NHS Foundation Trust
Following an unannounced inspection of the Emergency Department at the Cumberland Infirmary in February 2026, inspectors found areas of good practice as well as a number of concerns. CQC issued formal notification of a Section 31, which grants the CQC …
Cumberland Infirmary
Mar 2026
Conditions Imposed: Shrewsbury and Telford Hospital NHS Trust
The Care Quality Commission imposed urgent conditions on Shrewsbury and Telford Hospital NHS Trust's registration following inspections of its maternity and emergency departments. Inspections highlighted concerns regarding reduced foetal movements guidelines in maternity services and the treatment and recognition of …
Oct 2018
Conditions Imposed: The Princess Alexandra Hospital NHS Trust
The Care Quality Commission (CQC) placed conditions on The Princess Alexandra Hospital NHS Trust's registration following an inspection in July, August and September. This action was taken due to serious concerns found regarding the lack of monitoring of patients waiting …
Nov 2021
Conditions Imposed: Croydon Health Services NHS Trust
The Care Quality Commission (CQC) told Croydon Health Services NHS Trust that it must improve the quality of care provided to patients in mental health crisis in its urgent and emergency services at Croydon University Hospital. Following an unannounced, focused …
Croydon University Hospital
Dec 2020
Warning Notice: Gloucestershire Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Gloucestershire Hospitals NHS Foundation Trust following an unannounced inspection of urgent and emergency services at Gloucestershire Royal Hospital in December. The inspection was prompted by concerns from people using the …
Gloucestershire Royal Hospital
May 2024
Warning Notice: East Suffolk and North Essex NHS Foundation Trust
Inspectors served the trust a warning notice due to concerns about people’s safety and the management of these services. Staff weren’t able to triage everyone arriving at the emergency department within their goal of 15 minutes, and some people waited …
The Ipswich Hospital
Oct 2025
Warning Notice: Royal Cornwall Hospitals NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Royal Cornwall Hospitals NHS Trust following an announced inspection in December. The inspection assessed actions taken after seven 'never events' occurred within the trust's surgical care group and emergency department. …
Feb 2021
Warning Notice: Nottingham University Hospital NHS Trust
The Care Quality Commission (CQC) issued a warning notice to Nottingham University Hospital NHS Trust following an inspection in June and July. CQC found areas where improvements were needed, particularly around leadership, risk management, governance, and culture. Concerns included a …
Sep 2021
Warning Notice: Worcestershire Acute Hospitals NHS Trust
Following a focused inspection in April 2017, CQC issued a Warning Notice to Worcestershire Acute Hospitals NHS Trust. The notice requires the trust to take action to address concerns regarding governance systems and the mitigation of risks. Inspectors found no …
Aug 2017
Warning Notice: Sussex Partnership NHS Foundation Trust
Section 29A warning notice for failing to ensure consistently safe care of patients using mental health crisis services and health-based places of safety, and for governance systems that were not sufficiently robust.
Jul 2025