Care and discharge planning
Failure to develop detailed and comprehensive client assessments, recovery plans, and discharge plans.
1,557 items
13 sources
4 inquiries
Source spread
Where this theme appears
Care and discharge planning has been flagged across 13 independent accountability sources:
9 inquiry recs
519 PFD reports
36 committee recs
75 CQC actions
82 PPO recs
4 IOPC recs
4 PHSO recs
43 IMB reports
40 IMB recs
1 detention investigation rec
288 PHSO decisions
455 LGO/SPSO decisions
When the same issue appears across inquiries, coroner reports, and regulators independently, it indicates a recurring issue across the public record.
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 (9)
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
LAMI-71 — Require documented future care plan for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without a documented plan for the future care of the child. The plan must include follow-up arrangements. …
Unknown
LAMI-70 — Require consultant or paediatrician permission for discharging children with protection concerns.
Recommendation: Hospital trust chief executives must introduce systems to ensure that no child about whom there are child protection concerns is discharged from hospital without the permission of either the consultant in charge of the child’s care or of a paediatrician …
Unknown
R6 — Service change continuity plans
Recommendation: Scottish Government should ensure that where major changes in patient services are planned there should be clear and effective plans in place for continuity of safe patient care.
Gov response: Section 2.1 of the Scottish Government's response details the intention to develop a longer-term plan for health and social care, and the integration of health and social care services. This integration aims to improve care, …
Accepted
F239 — Continuing responsibility for care
Recommendation: The care offered by a hospital should not end merely because the patient has surrendered a bed – it should never be acceptable for patients to be discharged in the middle of the night, still less so at any time …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
BRIS-20 — Establish comprehensive counselling and support services as integral to patient care
Recommendation: The provision of counselling and support should be regarded as an integral part of a patient’s care. All hospital trusts should have a well-developed system and a well-trained group of professionals whose task it is to provide this type of …
Unknown
LAMI-56 — Prevent discharge of hospitalised children with concerns until home is safe
Recommendation: Directors of social services must ensure that no child known to social services who is an inpatient in a hospital and about whom there are child protection concerns is allowed to be taken home until it has been established by …
Unknown
F256 — Follow up of patients
Recommendation: A proactive system for following up patients shortly after discharge would not only be good "customer service", it would probably provide a wider range of responses and feedback on their care.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
BRIS-21 — Require every trust to provide a professional bereavement service and online information
Recommendation: Every trust should have a professional bereavement service. (We also reiterate what was recommended in the Inquiry’s Interim Report: ‘Recommendation 13: As hospitals develop websites, a domain should be created concerned with bereavement in which all the relevant information concerning …
Unknown
PFD Reports (519) — showing 50 strongest matches
John Fisher
Concerns: Poor information transfer between healthcare teams, inaccurate medication records, and inadequate handovers between care providers risk patients receiving incorrect or missed essential medication.
Responded
Nicola Matthews
Concerns: Incomplete documentation and unclear, undocumented follow-up arrangements for a high-risk patient discharged from inpatient care led to staff confusion and potential for future harm.
Overdue
John Walker
Concerns: Insufficient risk care planning, lack of rationale for decreasing observation levels despite deteriorating mental state, and delays in reporting missing patients raised serious safety concerns.
Response (Sussex Partnership NHS Foundation Trust): The Trust has revised the documents clinicians are asked to complete to ensure they are less repetitive and better support succinct recording of relevant issues and the fences throughout Langley …
Responded
Terence O’Connell
Concerns: A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Response (Gabbandco): The care home disputes that there was a communication breakdown between the care home, district nurses, and the out-of-hours GP service, asserting that communication breakdown was between district nurses and …
Response: The University Health Board has implemented a clear and accurate message sheet, SBAR (Situation, Background, Assessment, Recommendation), for switchboard staff to record out-of-hours requests for District Nurses in greater detail.
Overdue
Karen Sutton
Concerns: Hospital departments failed to share patient admission information, leading to discharge without prophylactic medication and inadequate follow-up arrangements due to a lack of Trust-wide communication policy.
Response (University Hospitals of Leicester): The Medical Director reminded consultants of their duty to contact specialist teams for patients with complex needs, and the hospital expects to have software by April 2014 to alert consultants …
Responded
Rose Jean Coles
Concerns: Inadequate communication and protocols between the neonatal intensive care and cardiac units hindered the safe care of premature babies, as the cardiac unit was not suited for their specific needs.
Response (University Hospital Bristol): University Hospitals Bristol has created a composite action plan to address concerns raised in two Regulation 28 reports and will monitor the plan's implementation through the Trust's governance procedures.
Responded
Douglas Grey
Concerns: Lack of clear written procedures for equipment delivery, installation, and review. Carers also failed to recognise and report faulty equipment despite a written policy, compromising resident safety.
Overdue
Rosa Anderson
Concerns: The patient was discharged without a summary, written information on her operation, critical advice, or emergency contact numbers.
Response (Aintree University Hospital): Aintree University Hospital has implemented a discharge advice sheet for laparoscopic procedures and is providing generic leaflets for all discharged patients, with specialties developing individualized discharge information sheets by March …
Responded
Kevin Paul Sutton
Concerns: The Trust failed to prepare essential care plans for patients discharged from its wards to other establishments, risking inadequate ongoing care.
Overdue
Rosemary Brownyn Ferguson
Concerns: Poor communication between hospital staff and Social Services led to a discharge without support. Unclear instructions given to a friend regarding patient care, combined with scanty hospital notes, created significant misunderstandings and risks.
Overdue
Stephanie Daniels
Concerns: Significant deficiencies exist in internal SUI investigations, with errors and omissions, along with concerns about the thoroughness and independence of inquiries. Additionally, patient information handover between staff was often inadequate.
Response (Manchester Mental Health NHS): Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning …
Response (Manchester Clinical Commissioning Groups): The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has …
Response (Department of Health): The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the …
Responded
Sean Seabourne
Concerns: Systemic communication failures and unclear roles between mental health teams led to an urgent referral for a high-risk patient with suicide plans not being acted upon, preventing a crucial face-to-face assessment.
Overdue
Christine Williamson
Concerns: Failure to assess the deceased as a vulnerable adult at risk from domestic violence and a critical lack of information sharing between agencies hindered preventative measures.
Response (Telford Wrekin Council): Telford & Wrekin Council has compiled a plan of action building upon recommendations made in the Domestic Homicide Review report, and the implementation of the action plan will be formally …
Response (Telford Wrekin Clinical Commissioning Group): The Adult Safeguarding Policy and Thresholds has been recirculated, domestic abuse leaflets and guidance has been circulated, and an education and training event for Telford & Wrekin GPs and Practice …
Response (West Mercia Police): West Mercia Police will provide a reminder regarding the requirement to complete DASH; Crime Reports and Vulnerable Adult documentation to all operational staff. The tactical equality and diversity advisor has …
Responded
Michael Longley
Concerns: Difficulties in communication between Integrated Care 24 and the District Nursing Service highlight a need for improved oral and written communication methods.
Overdue
James Edward Mansfield
Concerns: Delays in the GP surgery reviewing hospital discharge letters for serious injuries, combined with prescribing strong painkillers without an in-person assessment, posed risks to patient safety.
Overdue
Linda Hudson
Concerns: Hospital discharge of a high-risk patient without family notification, inadequate communication regarding medication protocols, and a delayed nurse follow-up visit created significant safety risks.
Overdue
John Malone
Concerns: A hospital discharge letter was critically deficient, lacking essential patient admission and discharge details, which hindered the GP's ability to provide appropriate ongoing care.
Overdue
Desrae Tucker
Concerns: Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
Overdue
Michael Irlam
Concerns: A significant 24-day waiting time between discharge from crisis mental health services and the first follow-up appointment creates a dangerous gap in care, risking patient abandonment.
Overdue
Ricky Anderson
Concerns: Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.
Overdue
Maureen Leaver
Concerns: Inadequate medical supervision and ineffective systems for investigating acutely ill elderly patients in a psychiatric ward were identified, alongside a lack of understanding of legal duties for patient transfers.
Overdue
Joan Mary Jones
Concerns: Care home staff failed to escalate a patient's deteriorating condition and provide complete information to health professionals, resulting in inadequate care and putting the patient at risk.
Response (The Manor): Following an inquest, the care home sent a memo to unit leads emphasizing communication protocols with families and healthcare professionals after GP visits. They also contacted the family and engaged …
Responded
George Renshaw Brown
Concerns: A lack of efficient systems for reassessing and transferring care home residents with rapidly deteriorating conditions led to significant delays in moving a patient to more suitable accommodation.
Overdue
Leslie Pates
Concerns: A complete breakdown in hospital and social services communication with the family occurred. The patient was discharged against family wishes with severe pressure sores and no pressure-relieving mattress.
Response (Tamside Hospital NHS): Tameside Hospital NHS describes several actions taken to improve communication regarding discharge plans, including developing a checklist, ensuring documented evidence of discussions with patients and carers, raising the profile of …
Overdue
Gareth Slater
Concerns: Discharge planning failed due to clinical impasses, resulting in no care plan, insufficient family involvement, inadequate independent living assessment, and an unsuitable unfurnished flat.
Overdue
Ryan Chapman
Concerns: Staff lacked understanding of patient leave policies and support worker roles. Delayed risk assessments, insufficient family information, and poor ward security were identified issues.
Overdue
Jack Lynn
Concerns: The absence of a continuous medication communication record and a safety/well-being check during a 15-minute care visit exposed the patient to potential risks.
Response (Nightingales Home Help Service): Nightingales Home Help Service will encourage clients to have medication charts and has advised staff to review their medication policy. They also provided a Safe Handling of Medication course for …
Responded
Jack William Partington
Concerns: Neonatal care suffered from inadequate nurse handovers, isolated treatment decisions, and a lack of routine exhaled carbon dioxide detector use. There were also no national policies for managing paralysing agents or neonatal ventilation.
Response (Department of Health): The Department of Health believes the issues are local and should be addressed by the Trust, noting existing guidance and the role of NHS England, but will notify the British …
Overdue
Alan Stanfield Browning
Concerns: A vulnerable patient was discharged from a care facility without family notification or proper accommodation arrangements, specifically on a Friday, highlighting a lack of robust discharge planning.
Overdue
John William Tugwell
Concerns: The care home allowed a high-risk patient with a documented history of falls unsupervised access to stairs, despite the clear potential for serious injury.
Overdue
Norma Sheppard
Concerns: The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Overdue
Derrick Plater
Concerns: There was no protocol for visiting care homes before placing patients with complex needs, relying solely on assurances. A lack of clear guidelines for when visits should be undertaken during assessment poses a risk.
Response: The council believes that a pre-placement visit by a social worker would not have provided any added assurance and is not and will not be part of the assessment and …
Responded
Graham Watts
Concerns: The hospital's discharge procedure was severely flawed, involving blank paperwork, lack of communication with family or care home, and discharging a medically unfit patient.
Response (Brighton Sussex University Hospitals NHS Trust): A social worker has started attending daily "Board Round" meetings to assist in patient discharge planning. The Trust acknowledges shortcomings in the discharge planning process and is aiming to start …
Responded
Roger Duggan
Concerns: An agitated patient was left unsupervised in the Emergency Department, and staff failed to take responsibility for monitoring him, leading to his unnoticed departure.
Response (Royal Devon Exeter NHS Trust): The staff nurse involved in the incident was reminded of the importance of contemporaneous record keeping. The Trust is using its Care Quality Assessment Tool (CQAT) to ensure that documentation …
Response (South Western Ambulance Service NHS Foundation Trust): Following an investigation, the Trust upgraded its version of 'NHS Pathways' to version 6.5.1, including a dedicated Mental Health Pathway, and trained staff on its use; a Mental Health Group …
Responded
Winifred Dennis
Concerns: Patient transfers between community nursing teams lacked formal handover documents, resulting in critical information, like the need for specific equipment, not being communicated to new care homes.
Response (Kent Community Health NHS Trust): Kent Community Health NHS Trust has devised a formal process for transfer of care between community nursing teams. A working group has been established to revise policies and procedures, improve …
Responded
Andrey Wakefield
Concerns: Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Response (University Hospital of North Staffordshire): A solution is being rolled out in three phases to improve communication of discharge information between the hospital and GPs, including remote implementation, training, IT support and standard operating procedures. …
Responded
Frank Pope
Concerns: There is no clear "back-up" process to ensure follow-up for patients lacking capacity, particularly when family members are not copied into correspondence, risking missed appointments.
Response (Whittington Health NHS): The Trust will send a communication to all GPs via the GP Bulletin to remind them to include any information with regard to vulnerable patients or patients who lack capacity …
Overdue
Ross Boyd
Concerns: An inadequate assessment of the deceased's needs resulted in an inappropriate placement at a care home, failing to meet his specific requirements.
Response (Milton Keynes Council): Milton Keynes Council reviewed the case and believes the placement was appropriate given the information available at the time. They will ensure managers discuss the use of respite beds with …
Pending
Jennifer Morrison
Concerns: Missing medical records hampered investigations, and bed shortages combined with inadequate staffing during peak holiday seasons led to prolonged assessment unit stays and treatment delays.
Response (Wirral University Teaching Hospitals NHS Foundation Trust): Wirral University Teaching Hospitals NHS Foundation Trust describes measures to manage medical records, including a Health Records Management Policy and regular audits. The Surgical Division now holds daily management meetings …
Responded
William Beckwith
Concerns: A frail, elderly patient with a history of falls was discharged home in the early morning without formal assessment of his or his wife's abilities, home environment, or essential post-discharge care needs.
Response: The hospital is undertaking a multidisciplinary review of its guidance for assessing elderly patients after a fall, with a clear policy expected by the end of August.
Responded
Audrey Garland
Concerns: Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate care and examination.
Response: Blackpool Teaching Hospitals NHS Foundation Trust held focus group meetings and discussed the Coroner's concerns with the District Nursing Team, resulting in an action plan monitored by the Head of …
Overdue
Peter Farebrother
Concerns: Failures in patient transfer, handover of observation status, and returning a ligature risk item (belt) led to an unsafe environment. The effectiveness of the "sloping door" design against hanging was also questioned.
Overdue
Farres Ikken
Concerns: Hospital staff lacked the authority to refer patients directly to community psychology services upon discharge, creating a gap in post-hospital care.
Overdue
Albert Flynn
Concerns: Care staff lacked adequate training to assess a deteriorating patient or administer prescribed medication, leading to a significant delay in treatment and neglect of critical medical history.
Response (Lester Aldridge LLP): HC-One Limited will re-emphasise the need to call for qualified assistance during individual supervision for staff and induction for new staff, and senior care staff involved in this incident will …
Responded
John Wilsher
Concerns: An inaccurate discharge letter and a lack of communication regarding pre-existing concerns about a care home's suitability led to an inappropriate patient placement.
Response (Norfolk Norwich University Hospitals NHS): The hospital trust has revised its template discharge letter and created an additional bespoke template for patients of the Older People's Medicine Department to improve the accuracy of discharge information …
Response (Norfolk County Council): Norfolk County Council Community Services has been working with colleagues to ensure feedback is given to those raising safeguarding concerns. Social care practitioners are linked to hospital wards caring for …
Responded
Hilda Thompson
Concerns: There was a significant failure in falls risk assessment upon admission, with no further review for 10 days, leaving the patient vulnerable. This oversight was exacerbated by poor note-taking.
Overdue
Gillian Crossley
Concerns: Inadequate documentation, insufficient patient observation and monitoring, poor discharge planning, and a breakdown in communication between care providers were identified.
Overdue
Nicholas Megginson
Concerns: Patients discharged post-surgery received inconsistent advice, both oral and written, regarding venous thromboembolism risks and critical signs requiring urgent medical attention.
Overdue
Sybil Roberts
Concerns: A patient's declining condition and mobility were inadequately assessed for falls risk upon admission and after hospital discharge, leading to repeated falls due to unupdated care plans.
Overdue
Ian Page
Concerns: Communication failures post-handover, lack of falls risk assessment, unavailability of a low bed, and inadequate staffing levels for high-need patients contributed to risks.
Overdue
Committee Recommendations (36)
#15 — Complex patient needs, longer hospital stays, and staff sickness impede NHS productivity recovery.
Recommendation: We asked witnesses why NHS productivity continues to be lower than before the pandemic. NHSE told us the NHS currently has 19% more staff compared to before the pandemic but is only seeing 14% more patients. It named several factors …
Gov response: 3.2 The NHS is working hard to recover lost productivity caused by the Covid-19 pandemic. The most recent ONS publication of annual Public Sector Productivity shows: • NHS productivity continuing to recover in 2022-23, after …
Accepted
#27 — Accelerate adult social care commission timescale and fully fund sector by Parliament's end
Recommendation: The timescale for the commission into adult social care should be brought forward, and it must present actionable reforms to the sector as part of its interim findings in 2026. The Government must not wait for the commission to publish …
Gov response: 78. Local authorities are independent employers responsible for the management of their own workforces and their own improvement – the government expects this will include ensuring their councillors and statutory officers have the right level …
Under Consideration
#26 — Proposed timescale for adult social care commission risks insufficient and delayed reform
Recommendation: While we support the new independent commission into adult social care led by Baroness Casey, we are concerned that the proposed timescale means that urgent reforms to social care services will not be implemented soon enough to overcome the severity …
Gov response: 77. The Government has always maintained transparency regarding which councils have been in receipt of EFS and the amount of support provided. As part of the EFS framework, councils are required to undergo an external …
Under Consideration
#25 — Inaction on adult social care reform creates unsustainable human and financial costs
Recommendation: We support and echo the conclusions of the recent report Adult Social Care Reform by the Health and Social Care committee. As they have said in the summary of their report, successive Governments have not fully considered the human and …
Gov response: 76. The Government is committed to improving how we assess the need to ensure central government funding is distributed fairly to the places who need it most. The Government recognises the importance of transitional arrangements …
Under Consideration
#18 — Publish annual official estimates of delayed discharge costs to the NHS, broken down by reason
Recommendation: We recommend that the Department provides an official estimate of how much delayed discharges are costing the NHS, broken down by the reason for the delay and including costs associated with the beds themselves, staff time and wider activity that …
Gov response: We agree that publishing cost estimates broken down by delay reason would in principle improve transparency about the impact of delayed discharges. There are some methodological challenges involved in estimating costs attributable to delayed discharge, …
Under Consideration
#17 — Inadequate adult social care system imposing significant costs on the NHS, particularly from delayed discharges
Recommendation: Social care is a vital public service in and of itself and should not be valued only for how it supports the NHS. However, the current state of adult social care is imposing significant costs on the NHS. The best …
Gov response: We agree that publishing cost estimates broken down by delay reason would in principle improve transparency about the impact of delayed discharges. There are some methodological challenges involved in estimating costs attributable to delayed discharge, …
Under Consideration
#6 —
Recommendation: As emphasised by Alzheimer’s Society and other key stakeholders, social care reform must be “rooted in the recognition of what good quality care looks like” and 20 Supporting people with dementia and their carers create a system where people with …
No Published Response
#5 —
Recommendation: We recommend the Department of Health and Social Care and NHS England and Improvement use the White Paper to develop clear guidance on the care and support those living with dementia and their carers should expect to receive from diagnosis …
No Published Response
#4 —
Recommendation: However, the evidence we have taken has made it clear that improving diagnosis alone is not sufficient: people living with dementia and their carers need appropriate post- diagnostic support throughout the rest of their life. We are clear that there …
No Published Response
#19 — Delayed hospital discharges increased by 12% in 2022-23, due to complex patient needs.
Recommendation: The number of patients staying in hospital despite no longer needing to be there averaged 13,623 across Q4 of 2022–23, an increase of 1,505 or 12% compared with 12,118 during the same period in 2021–22.49 We asked NHS England why …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million …
Accepted
#4 — Set out actions to address delayed discharges caused by hospital, community, and social care constraints.
Recommendation: Not enough is being done to tackle delayed discharges, which cause inefficiencies both within hospitals and more widely across the care system. Delays with discharging patients when they are medically fit for discharge reduces available bed capacity, which in turn …
Gov response: The government agrees with the Committee’s recommendation. Recommendation implemented The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million invested in …
Accepted
#21 —
Recommendation: We asked for assurance that there would be enough additional capacity outside of hospitals, given that new community services would be funded separately from the NHP. NHS England told us that this was at the heart of its 10-year plan. …
Response Pending
#20 —
Recommendation: We asked the Department how it had concluded that the new hospitals required more beds than those they were replacing given that its 10-year health plan aims to shift of care out of hospitals and into the community.41 The Department …
Response Pending
#4 —
Recommendation: The Department has not yet developed a convincing rationale for the proposed size of new hospitals or how larger hospitals complement aspirations for new models of care and reducing demand in hospitals. Shifting care out of hospitals and into the …
Response Pending
#20 —
Recommendation: We asked the Department what the £500 million Adult Social Care Discharge Fund would achieve. It informed us this funding would be used primarily for measures to support discharge from hospitals into social care, with an expectation that much would …
Gov response: 3.5 The government agrees with the Committee’s recommendation. Target implementation date: July 2023 3.6 The government provided £500 million for 2022-23 to support timely and safe discharge from hospital into social care. Analysis of the …
Not Addressed
#21 — Facilitate integrated working between health and social care services to reduce delayed discharges.
Recommendation: We have previously noted that the fragility of the adult social care provider market was exacerbating the difficulties in discharging older patients from hospital.55 NHS England agreed that there is a clear challenge in social care. Different solutions are needed …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million …
Accepted
#20 — Delayed hospital discharges attributable to four categories, including hospital processes and social care.
Recommendation: NHS England told us that the reasons why patients might experience delays in leaving hospital could be divided into four categories. For one group of patients, accounting for around 20%, the delays are related directly to activity in the discharging …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million …
Accepted
#12 — Short-term hospital discharge funding shows positive impact but avoids systemic issues.
Recommendation: With regard to additional funding for hospital discharge—£600 million in 2023– 24 and £1 billion in 2024–25—the Department told us that delayed discharges had been consistently lower over the last 6 months than the previous year despite an increase in …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Recommendation implemented 2.2 Since Spending Review 2021, the government has made available up to £8.6 billion in additional funding over 2023-24 and 2024-25 for adult social care …
Accepted
#180 —
Recommendation: The lack of available testing for social care was particularly damaging, as we discuss in more detail later in this Report. Crucially, it was not until mid-April that covid-19 testing was made a requirement for people discharged from hospital to …
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#180 —
Recommendation: The lack of available testing for social care was particularly damaging, as we discuss in more detail later in this Report. Crucially, it was not until mid-April that covid-19 testing was made a requirement for people discharged from hospital to …
Gov response: The government recognises and has responded to the impact of the pandemic on the social care sector. The Prime Minister’s announcement of the ‘Build Back Better’ plan for health and social care in September 20213 …
Under Consideration
#22 — NHS England's current discharge speed-up processes show inconsistent results across the country.
Recommendation: NHS England told us it had instructed the NHS to speed up discharge processes, for example by minimising waits for supporting services such as transport and medications. It was also asking hospitals to monitor patients more closely to assess whether …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million …
Accepted
#18 — Interdependency of urgent and emergency care services creates system-wide bottlenecks from issues.
Recommendation: The different services for urgent and emergency care are highly connected and interdependent, meaning that issues in one service impacts throughout the rest of the system.46 If the NHS is unable to discharge patients from hospitals when they no longer …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Recommendation implemented 4.2 The Department of Health and Social Care is investing an additional £1.6 billion over 2023-24 and 2024-25, on top of the extra £500 million …
Accepted
#44 — Publish details of work ensuring continuity of care for women from prison to release.
Recommendation: Continuity of care for women on short and longer sentences is fundamental to successful resettlement. The MoJ and HMPPS should set out what work they are doing to ensure that women experience continuity of care from prison through to release. …
Gov response: We accept this recommendation. Under the resettlement approach, all women’s prisons will have an embedded pre-release team based in the prison. The embedded pre-release teams will provide pre-release support not currently available via Commissioned Rehabilitative …
Accepted
#15 — Provide updates on IPP prisoner resettlement, detailing Resettlement Passports and pre-release preparation
Recommendation: We welcome the Government’s commitment to ensuring that all prison leavers leave prison with the basics, such as ID and a bank account, and ask that updates on this programme of work be provided to us. We would also welcome …
Gov response: Accept Reasoning: We recognise that individuals who are released with a job, a home and support with substance misuse issues are less likely to reoffend. That is why, in 2021, the government announced an additional …
Accepted
#10 — Inadequate regulation of exempt accommodation permits widespread provision of substandard housing.
Recommendation: Exempt accommodation can provide much-needed homes and support including for people recovering from drug or alcohol dependence; at risk of or transitioning to or from homelessness; or on release from the criminal justice system. However, the NAO found that some …
Gov response: 2.1 The government agrees with the Committee’s recommendation. Target implementation date: Winter 2023 2.2 DLUHC will publish a consultation in early 2024 on the detailed design of the measures set out in the Supported Housing …
Accepted
#27 — Probation Service faces significant increase in demand for resettlement services
Recommendation: As these additional prisoners progress through their sentences, there will be higher demand for resettlement services. MoJ’s central estimate in its recent modelling work on forecast volumes of prison leavers starting their supervision in the community shows that, while projections …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: May 2024 The MoJ will respond to the Committee by the six-month deadline, setting out the projections for its prison population, bringing six new prisons …
Not Addressed
#22 — Long-term accommodation outcomes for prison leavers remain challenging despite HMPPS investments.
Recommendation: MoJ told us it is working with HMPPS to better understand what works best on accommodation support for prison leavers.52 Outcomes have remained stable in recent years despite HMPPS’ investments, with 76% of prison leavers from April 2022 to February …
Gov response: 5.1 The government agrees with the Committee’s recommendation. Recommendation implemented 5.2 Detailed evaluation plans, based on best practice set out in HM Treasury’s Magenta Book, are now in place to assess the effectiveness of HMPPS …
Accepted
#7 — Inconsistent delivery of prison resettlement services undermines effective support for prison leavers.
Recommendation: HMPPS told us one of its biggest concerns is whether it can consistently deliver its vision for probation services across all corners of England and Wales.13 In 2022–23, an HMPPS review found 14 out of 27 key events in the …
Gov response: The government agrees with the Committee’s recommendation. Target implementation date: May 2024 HMPPS is committed to ensuring that resettlement services provide consistent and adequate support to prison leavers, to reduce reoffending and protect the public. …
Accepted
#58 — Continuity of care is vital; swift Government action needed to improve social care retention.
Recommendation: The value of continuity of care in social care settings, particularly for people who rely on non-verbal communication, is undeniable. It is essential that the Government acts swiftly to implement the findings of this report to improve retention in the …
Gov response: We agree with the Committee that continuity of care is vitally important to good quality of care. We are committed to working with local authorities and independent providers to address the recruitment and retention challenges …
Not Addressed
#23 — Stop moving pregnant asylum seekers and new mothers without clinical consent and collect related data.
Recommendation: The Home Office must stop moving pregnant women and new mothers between asylum accommodation settings unless clinical advice has been sought and acted on, the mother has consented to a move, and it is in the mother’s and baby’s best …
Gov response: We recognise the particular vulnerability of pregnant women and new mothers and are committed to ensuring that they receive the support they need. Our policy is clear that moves should only be made where advice …
Partially Accepted
#22 — Home Office compliance failures endanger pregnant asylum seekers and new mothers during accommodation moves.
Recommendation: The Home Office is too often failing to comply with guidance on moving pregnant women and new mothers between asylum accommodation settings. The guidance is clear that such moves are potentially harmful and should only be made where advice on …
Gov response: We recognise the particular vulnerability of pregnant women and new mothers and are committed to ensuring that they receive the support they need. Our policy is clear that moves should only be made where advice …
Partially Accepted
#1 — Committee took evidence on progress in reforming adult social care in England.
Recommendation: On the basis of a report by the Comptroller and Auditor General, we took evidence from the Department of Health and Social Care (the Department) and from the Department for Levelling Up, Housing and Communities (DLUHC) about progress in reforming …
Gov response: The government agrees with the Committee’s recommendation. government, social care providers and other organisations work together to provide joined-up care and improved outcomes. Through new Care Quality Commission (CQC) assurance of ICSs and local authorities …
Accepted
#11 — Strengthen consumer standards to ensure providers act on tenants' regeneration views.
Recommendation: We welcome the Regulator’s efforts to ensure that regeneration projects are properly explained to tenants, and that tenants have had some opportunity to share their views. However, we believe the Regulator must go further to ensure registered providers not only …
Gov response: 17. We agree with the committee about the importance of providers explaining regeneration projects to tenants, listening to and taking account of their views, and ensuring appropriate information is provided about what has been done …
Accepted
#10 — Insist regeneration projects fully account for and meet existing tenants' needs.
Recommendation: Regeneration should respect the experience of existing tenants, whose lives will be disrupted, as well as those who will benefit from the new or additional homes in the future. An additional challenge is presented when estates contain both social housing …
Gov response: 15. In setting standards the regulator must have regard to the desirability of registered providers being free to choose how to provide services and conduct business.8 Therefore our standards do not detail how providers should …
Not Accepted
#2 — Take action based on heard concerns regarding disabled people’s housing needs
Recommendation: We have found little evidence that the Department for Levelling Up, Housing and Communities is fully recognising the housing needs of disabled people, let alone treating disabled people’s needs as a priority in housing policy. In particular, it is deeply …
Gov response: 9. We note that this recommendation relates specifically to a commitment made by the previous government. This government is committed to ensuring that our housing market works for everyone, including disabled people. We recognise that …
Under Consideration
#1 — Prioritise disability inclusion and address housing barriers faced by disabled people
Recommendation: Disabled people are not a homogeneous group with a single set of housing needs. Rather, Government policy must seek to address the many barriers which disabled individuals face, which vary widely. Too often too many disabled people are failed by …
Gov response: 6. The Committee refers to the Disability Action Plan published by the previous government on 5 February 2024 and oral evidence from the previous government. This government notes the conclusion of the previous Committee’s inquiry. …
Under Consideration
CQC Inspection Actions (75) — showing 50 strongest matches
Verve Health
The service must ensure that staff complete personal discharge plans and provide harm reduction advice for all service users leaving the service in order to safely support service users when they return to the community.
Must Do
Trent Lodge Residential Care Home
The registered person must ensure that each service user is protected against the risks of receiving care and treatment that is inappropriate or unsafe by means of the carrying out of an assessment of the needs of the service user …
Must Do
Kingsley Nursing Home
People using the service were unlawfully deprived of their liberty, due to delays in submitted Deprivation of Liberty Safeguards (DoLS) authorisation applications to the Local Authority.
Must Do
Derriads
The principles of the Mental Capacity Act 2005 were not followed. People's capacity to make complex decisions about their care was not assessed. Best interest decisions that led to restricting people's liberty had not followed.
Must Do
Eleanor House
The provider must take action regarding the implementation of effective pressure care management.
Must Do
Valewood House Nursing Home
Care had not been planned and delivered in such a way as to ensure the welfare and safety of people or to meet their individual needs.
Must Do
Southwinds
The provider did not make arrangements to respond appropriately and in good time to people's changing needs.
Must Do
Reside at Southwood
The service had not acted in accordance with the requirements of the Deprivation of Liberty Safeguards.
Must Do
Reside at Southwood
Suitable arrangements were not in place for acting in accordance with the Mental Capacity Act 2005.
Must Do
Park Grange Care Home
The care plans did not contain decision specific mental capacity assessment or best interest decisions.
Must Do
Kingsley Nursing Home
The provider had failed to notify the Care Quality Commission of Deprivation of Liberty Safeguards (DoLS) authorisations as required by law.
Must Do
The Gateway
Staff were not ensuring that people were not inappropriately subject to deprivation of liberties or that DoLS authorisations were sought.
Must Do
Applegarth Care Home
The provider must ensure that there are records of best interest meetings that involve the person, their relatives or other health professionals, to look at the least restrictive options.
Must Do
Valewood House Nursing Home
The provider must ensure care is planned and delivered in such a way as to ensure the welfare and safety of people and to meet their individual needs.
Must Do
Reside at Southwood
Arrangements were not in place to ensure that the service acted in accordance with the Mental Capacity Act 2005.
Must Do
Park Grange Care Home
The care plans did not contain decision specific mental capacity assessment or best interest decisions.
Must Do
Park Cottages
People's right were not protected in line the Mental Capacity Act because decision specific mental capacity assessment and best interest decisions were not in place and appropriate DoLS applications had not been made. Care plans were not signed by the …
Must Do
Chatting Independently Limited - Rectory Drive
People who used services were not protected against the risks of receiving care and treatment that is inappropriate or unsafe by means of the planning and delivery of care and, where appropriate, treatment in such a way as to meet …
Must Do
Chatting Independently Limited - Orchard View
The provider must ensure people who used services are protected against the risks of receiving care and treatment that is inappropriate or unsafe by means of the planning and delivery of care and, where appropriate, treatment in such a way …
Must Do
Ashmore House
The provider must plan people’s care to protect them from the risks of receiving care which is inappropriate or unsafe.
Must Do
Dalwood FarmHouse
The registered manager had not ensured risks to the health, safety and welfare of people who use the service were assessed and kept under review.
Must Do
Brook House Residential Home
Address gaps in the decision-making processes followed for people lacking the mental capacity to make their own decisions in key areas, such as refusing prescribed medicines or sharing bedrooms.
Must Do
St.Theresa's Nursing Home
The registered person had not notified the commission of requests made to the supervisory body for a standard authorisation. Regulation 18 (1) (4A) (a).
Must Do
Pennsylvania House
The provider must ensure people who use services are protected against the risks of receiving unsafe or inappropriate care by documenting risks to people and having a plan to manage these risks.
Must Do
Laurel Lodge Care Home
The provider must ensure that care and treatment is provided only with the consent of the relevant person, and that staff understand and apply the principles of the Mental Capacity Act and Deprivation of Liberty Safeguards.
Must Do
Laurel Lodge Care Home
The provider must ensure that all reasonable steps are taken to ensure the risks to people are minimised.
Must Do
Dr French Memorial Home Limited
We recommend the service introduce a pre-admission assessment process to support people's safe transition into the service.
Should Do
Ashdale Care Home
At the last inspection, the principles of the mental capacity act were not followed. At this inspection, documentation had not changed, and a member of the management team advised that similar processes would be followed.
Must Do
Wii Care Limited
We recommend the provider and registered manager seeks advice, guidance and training from a reputable external source to ensure a greater understanding of the Mental Capacity Act 2005, ensuring people's basic rights are not undermined.
Should Do
The Old Rectory
The provider was not acting in accordance with the Mental Capacity Act 2005. Where people were people were unable to consent, mental capacity assessments had not been completed and best interests decisions had not been evidenced. Regulation 11 (1).
Must Do
The Grange Residential Home
The service was not complying with the Mental Capacity Act
Must Do
Stirling Park Residential Home
Care and treatment of service users must only be provided with the consent of the relevant person. (2) Paragraph (1) is subject to paragraphs (3) and (4). (3) If the service user is 16 or over and is unable to …
Must Do
St Albans House
The provider should ensure people's ability to make specific decisions is formally assessed by staff and recorded.
Should Do
Shenstone Hall Nursing Home
The provider must ensure that risk assessments and risk management plans are completed promptly for all people and kept up-to-date to ensure staff have the information needed to support people safely.
Must Do
Rosglen Residential Home
The provider should discuss with the person and their social worker to establish the most appropriate method for managing their finances, considering alternatives and ensuring capacity assessments are in place where appropriate, as there was no information or capacity assessment …
Should Do
Parkside Residential Home
Care plans lacked assessments of people's capacity to make decisions, best interests decisions for people who lacked capacity and consents.
Must Do
Oasis Community Care Ltd
Risk assessments not being in place as necessary, updated, and reviewed is a breach of Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Must Do
Oak Tree Manor
However, these did not always identify areas that needed developing further. For example, issues in relation to MCA and best interest.
Should Do
Oak Tree Manor
Most people were supported in accordance with the principles of the Mental Capacity Act 2005, however, documentation needed improving.
Should Do
Manor Rest Home
The provider must ensure people's consent and best interest decisions are obtained in line with legislation and guidance with MCA 2005 and DoLS.
Must Do
Lady Ida Lodge
People had not received a service consistent with their assessed care needs as they experienced late and missed calls.
Must Do
Kingston House
The service consults a reputable source to further develop end of life planning.
Should Do
Georgiana Care Home
We recommend the provider reviews end of life care planning for people to ensure plans are in place that fully reflect people's needs and preferences at this time.
Should Do
Foxleigh Grove Nursing Home
The provider takes action in line best practice when admitting new service users to the home, making sure there is a robust system to ensure assessments of people's needs are comprehensive and expected outcomes are identified.
Should Do
Devenish House
The provider had not ensured that decisions made on behalf of people who lacked the capacity to make their own decisions were made in accordance with the MCA (2005).
Must Do
Dalwood FarmHouse
The registered manager had not ensured the service followed the principles of the Mental Capacity Act 2005 when people were not able to consent to their care. Regulation 11 (3).
Must Do
Clova House Residential Care Home
Care and treatment of service users must only be provided with the consent of relevant people. If the person is unable to give such consent because they lack capacity to do so, then the provider must act in accordance with …
Must Do
Woodland Care Home
The provider takes action to ensure staff understand the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005.
Should Do
Taplow Manor
The provider should ensure all patients have discharge planning detailed in their care records.
Should Do
Southwinds
The provider must act in accordance with the Mental Capacity Act 2005 and associated code of practice.
Must Do
PPO Death in Custody Recommendations (82) — showing 50 strongest matches
The Head of Healthcare
The Head of Healthcare to ensure that all patients who have life limiting conditions have an advanced care plan in place in accordance with the National Institute for Health and Care Excellence (NICE) guideline [NG142] for ‘end of life care …
The Head of Healthcare
The Head of Healthcare should undertake an audit of hospital discharge plans to ensure that the agreed plan has been enacted and develop an action plan based on the findings.
The Governors and Heads of Healthcare of HMP Dartmoor and …
The Governors and Heads of Healthcare of HMP Dartmoor and HMP The Verne should ensure that they follow PSI 03/2016 when considering transfers for prisoners receiving local authority care and support.
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC …
HMPPS, working in partnership with Ministry of Justice, ADASS, DHSC and NHS England, should explore options for developing a pathway for prisoners who have been assessed as needing residential social care to access an appropriate care setting. This work should …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that when a prisoner returns from hospital: • their healthcare needs are assessed if they are in any of the categories at paragraph 4 of Annex D of PSI 07/2015; and • …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that applications for early release on compassionate grounds for prisoners with terminal illnesses are prioritised, and that a record is kept of action taken.
The Head of Healthcare
The Head of Healthcare should ensure that newly arrived prisoners with long-term medical conditions are managed appropriately, including: • prompt referrals to the GP at the prison; • offering a further opportunity for a secondary health screen if a prisoner …
The Head of Healthcare
The Head of Healthcare should ensure that patients with multiple healthcare needs are discussed at the multi professional complex case conference meeting so that the MDT has full oversight of their complex care and multiple care needs.
The Head of Healthcare
The Head of Healthcare should ensure that the appropriate persons are being discussed in the multi professional complex case conference (MPCCC) so that the wider healthcare team have full oversight of their needs.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should implement a process to ensure that healthcare staff are notified when prisoners return from hospital and that all discharge information is shared promptly to inform care planning.
The Head of Healthcare
The Head of Healthcare should ensure that processes and systems are in place regarding release and discharge planning for all prisoners known to healthcare and who require ongoing healthcare input.
The Head of Healthcare
The Head of Healthcare should ensure that a clear plan is documented within the patients SystmOne records following self–discharge from the hospital acute Trust to ensure that all outstanding care/treatment is re-initiated as soon as possible.
The Head of Probation Delivery Unit for Dyfed-Powys
The Head of Probation Delivery Unit for Dyfed-Powys should ensure that when a risk is identified, appropriate referrals are promptly completed to the relevant community services.
The Regional Probation Director
The Regional Probation Director should ensure that accurate and up to date information about a resident’s risk is shared with AP staff prior to their arrival, in line with national instructions.
The Local Delivery Unit Manager of North & Northeast Lincolnshire …
The Local Delivery Unit Manager of North & Northeast Lincolnshire Probation Service should ensure that community offender managers check that necessary referrals have been made to community-based support services prior to release.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that release planning processes are timely, collaborative and robust, including that appropriate referrals are made to community mental health providers for prisoners with complex needs and ongoing self-harming behaviour.
The Head of Healthcare
The Head of Healthcare should engage with a senior clinical hospital colleague in order to improve the discharge information process between the hospital provider and HMP Stafford.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff explore alternative environments for delivering care to prisoners isolating with COVID-19 – including in-cell assessment – to ensure that care is received in a timely manner.
The Head of Healthcare
The Head of Healthcare should ensure that all patients who have a terminal diagnosis (irrespective of prognosis) have an advanced care plan in place in accordance with the NICE guideline [NG142] for ‘end of life care for adults: service delivery’ …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • healthcare staff assess prisoners in reception when they return from hospital; and • there is effective written communication of clinical risks and health needs of prisoners returning from hospital and …
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should ensure that hospital discharge summaries for prisoners are received in a timely manner and, if this does not happen, that requests are followed up promptly.
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should ensure that all prisoners are assessed by the healthcare team on their return from hospital.
The Director and the Head of Healthcare at Parc
The Director and the Head of Healthcare at Parc should liaise with the local Health Board to ensure that newly arrived insulin-dependent diabetic prisoners are assessed on their understanding of diabetes management and self-care so that appropriate care is provided …
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff receive training on the Mental Capacity Act and that staff know when and how to assess mental capacity.
The Head of Healthcare
The Head of Healthcare should ensure that there are robust processes in place for communicating with hospitals to ensure that information is appropriately shared and discharge planning is completed.
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners returning from inpatient stays in outside hospital are treated in line with expected standards, including that: • all prisoners returning via Reception are seen and assessed by healthcare staff; and • …
The Head of Healthcare
The Head of Healthcare should ensure that all healthcare staff undertake a risk assessment when an adult presents with risk factors that make them at increased risk of dehydration and ensure that a plan of care is in place.
The Head of Healthcare
The Head of Healthcare should ensure that staff create care plans for prisoners at risk of cardiovascular disease.
Head of Knowsley and St Helens Probation Delivery Unit
The Head of Knowsley and St Helens Probation Delivery Unit should ensure all COMs understand their responsibilities within release planning and are aware of the need to complete relevant referrals for prisoners with mental health needs.
The Head of Healthcare
The Head of Healthcare should ensure that care plans are created to support in the management of incontinence as per NICE ‘When should I suspect a urinary tract infection in a man’ (2024).
The Head of Healthcare
The Head of Healthcare should ensure that prisoners with epilepsy are referred to a doctor, placed on a long-term care pathway and have a care plan.
The Governor
The Governor should ensure that all newly arrived prisoners receive an ‘Induction to Custody presentation’ in line with the expectations of PSI 07/2015 and that the local induction process is reviewed to ensure support is available for prisoners that arrive …
The Head of Service at East Midlands Probation Delivery Unit
The Head of Service at East Midlands Probation Delivery Unit should ensure that Community Offender Managers complete appropriate referrals to community services in preparation for a prisoner’s release, including when there are licence conditions in place, to allow for continuation …
The Head of Healthcare at Isle of Wight
The Head of Healthcare at Isle of Wight should ensure that healthcare staff arrange a proper handover to the receiving prison where a prisoner has more complex health care needs.
The Governor of HMP Downview
Downview has protocols for support following deaths in custody, but there do not appear to be formalised procedures for deaths following release. Deaths shortly after release are not frequent and so the situation may not have arisen previously, but the …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that there is a process in place to transfer prisoners with a terminal diagnosis or whose medical needs cannot be met at The Verne to a more suitable environment at the earliest …
The Head of Healthcare at HMP Thameside
The Head of Healthcare at HMP Thameside should ensure that prisoners are discharged or transferred with a sufficient supply of their prescribed medications.
The Head of Healthcare
The Head of Healthcare should ensure that a care plan is created for prisoners who are at increased risk of suicide or self-harm.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners with complex care needs are added to the multi-disciplinary team caseload.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should explore alternative options for meeting a prisoner’s care needs when they cannot be met on a standard wing.
The Director and Head of Healthcare
The Director and Head of Healthcare should ensure that applications for early release on compassionate grounds contain an up-to-date letter from the relevant hospital consultant, including all of the information required by the Early Release on Compassionate Grounds Policy Framework.
The Head of Healthcare
The Head of Healthcare should ensure that there is an auditable process to manage long-term medical conditions in line with the National Institute for Health and Care Excellence (NICE) guidelines, including: timely and appropriate referrals after reception health screens; implementation …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff complete all post-operative actions requested in hospital discharge summaries.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff request hospital discharge summaries when they are not routinely provided.
The Head of Healthcare
The Head of Healthcare should ensure that individualised care plans are created for prisoners with acute and complex physical health needs.
The Head of Healthcare
staff use appropriate clinical assessment and monitoring tools.
The Governor and Head of the Offender Management Services at …
The Governor and Head of the Offender Management Services at Bristol will want to consider whether any changes to existing processes would have prevented Mr Andrews being released in error.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are involved in their end-of-life care where practicably possible and that patient involvement in these discussions is recorded in the clinical notes.
The Commissioner for Health and Justice NHS England South East
The Commissioner for Health and Justice NHS England South East should work collaboratively with commissioned healthcare providers in custodial settings to formulate a regional approach and implement a process on when to recommend cell sharing for prisoners with life-threatening long-term …
The Governor
The Governor should ensure that the review of the prison debt strategy considers care planning for known debtors and ensures that all agreed care plans are recorded on the prisoner’s record and therefore available for all staff to see.
IOPC Learning Recommendations (4)
Police contact with man preceding murder – Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Constabulary should explore ways to highlight previous incidents, in respect of a person or address; when a new incident log is created or when the information is sought. Police responded to five separate calls over …
Police contact with man preceding murder – Derbyshire Constabulary, February 2020
The IOPC recommends that Derbyshire Police should write and implement a comprehensive Vulnerable Adult Policy that incorporates ACPO guidance and complements existing local authority safeguarding policies. As a result of this incident, Derbyshire Police have introduced guidance and learning for …
Recommendation - Wiltshire Police, July 2020
The IOPC recommends that Wiltshire Police create/implement guidance in relation to transporting detainees. Any new guidance and training should reflect: When the detainee was transported to custody, the journey was approximately 53 minutes. CCTV from inside the prisoner transport van …
Man sustained a serious injury while in custody – Cleveland Police, August …
The IOPC recommends that Cleveland Police should take steps to ensure that custody officers follow Authorised Professional Practice when determining and recording levels of obsevation for detainees. This should include consideration of whether: This follows an incident where a man …
PHSO Ombudsman Recommendations (4)
Discharge from mental health care: making it safe and patient-centred
NHS England should extend the requirement for a follow-up check within 72 hours of discharge for people from inpatient mental health settings to include people discharged from emergency departments.
Discharge from mental health care: making it safe and patient-centred
We note the Department of Health and Social Care's (DHSC) national statutory guidance on discharge from mental health settings. As it is implemented, DHSC and NHS England must engage with people and services to assess the impact the guidance has …
Discharge from mental health care: making it safe and patient-centred
NHS England should make sure that patients and their support network are active and valued partners in planning transitions of care and are empowered to give feedback, including through complaints.
Discharge from mental health care: making it safe and patient-centred
NHS England and Integrated Care Boards should make sure that people who are being discharged from mental health settings can choose a nominated person to be involved in discussions and decision-making around transitions of care.
IMB Annual Reports (43)
The Verne (2023)
HMP The Verne maintains a generally safe and respectful environment, successfully implementing a new self-harm monitoring system and demonstrating strong staff-prisoner relationships. The Board commends the high-quality physical healthcare provision, including excellent vaccination rates, and welcomes the establishment of a new 16-room social care unit aimed at addressing the long-standing concern for elderly and frail prisoners. However, significant challenges persist, particularly in resettlement provision, severe understaffing in the Offender Management Unit leading to backlogs, and long waiting times for mental health services and external healthcare appointments due to staff shortages.
PRISON
Key concerns
Ashfield (2020)
HMP Ashfield continues to be a well-run Category C prison for men serving sentences for sexual offences, known for its safe environment and humane treatment. Despite the significant impact of the COVID-19 pandemic on daily regime and programme delivery, staff were highly commended for their support and resilience. Key concerns include the persistent lack of suitable accommodation for release, issues with property management from other establishments, and the growing backlog for intervention programmes due to COVID-19 restrictions, which could hinder prisoner progression and parole.
PRISON
Key concerns
Bedford (2020)
Conditions at HMP/YOI Bedford generally improved over the reporting year, with commendations for the Governor's leadership, particularly during the COVID-19 crisis. While prisoner-on-prisoner assaults and self-harm incidents reduced, staff assaults and use of force remained worryingly high. Significant concerns persist regarding the ACCT process, the physical state of the segregation unit, and the high number of prisoners released without stable accommodation. Healthcare was satisfactory, but the mental health team's working practices require review, and issues with the Victorian estate infrastructure and the perceived unfairness of the IEP scheme need addressing.
PRISON
Key concerns
Charter Flight (2020)
The IMB Charter Flight Monitoring Team's 2020 report highlighted grave concerns regarding the inhumane treatment of vulnerable detainees, particularly Dublin Convention returnees who had recently self-harmed, with no health information shared with receiving countries. It noted unacceptably long periods of confinement in vehicles during transfers, lack of privacy during WC use, and inconsistent provision of information and support. The Board welcomed improved HOIE oversight and more consistent information provision by escorts, but reiterated several unaddressed recommendations regarding welfare and procedural fairness.
PRISON
Key concerns
Gatwick, Stansted, Luton and Lunar House (2020)
The IMB report for Gatwick, Stansted, Luton Airports and Lunar House covers the period January to December 2020. It notes that while staff generally treated detained individuals fairly and humanely, significant concerns exist regarding the physical limitations of the holding rooms, which lack natural light, fresh air, and adequate washing facilities. A primary concern is the inadequate arrangements for monitoring medical welfare and accessing urgent medication, compounded by the absence of trained medical staff on site. The Board made recommendations to the Home Office and Detention Contractor to address these healthcare deficiencies.
PRISON
Key concerns
Thorn Cross (2021)
HMP/YOI Thorn Cross continued to be a safe and respectful environment, despite the challenges of the Covid-19 pandemic. The Board noted good healthcare provision and a strong rehabilitative culture, supported by the welcomed use of mobile phones. Key concerns include the national reduction in open estate places, insufficient resources for prisoners with complex needs, and persistent issues with IT systems and missing property during transfers.
PRISON
Key concerns
Dover (2020)
The Independent Monitoring Board for Dover Short-Term Holding Facility reported on the period of January 2019 to December 2020, during which detainee numbers significantly increased. Key concerns included the unsuitability of the facilities for the high volume of detainees and extended stays, particularly for vulnerable individuals and children. The Board highlighted issues with mental health provision, the practicality of COVID-19 measures, and detainees' lack of clear information or external contact, despite staff largely treating detainees with respect.
PRISON
Key concerns
Stocken (2021)
HMP Stocken, a category C training prison, experienced significant disruption during the reporting year (May 2020 – April 2021) due to the Covid-19 pandemic, yet managed a commendable response to the outbreak and achieved high vaccination rates. Despite an extended period of restricted regime, the Board found the prison generally safe and commended the leadership and staff. Key concerns include persistent issues with prisoner transfers, resettlement support, and access to programmes.
PRISON
Key concerns
The Verne (2021)
HMP The Verne experienced a challenging year due to the COVID-19 pandemic, which caused a major outbreak, significant staff absences, and disruption to the prison regime, including education, work, and visits. Despite these challenges, the prison maintained a very safe environment with low violence, and the Board commended staff dedication and the strong ethos of mutual respect. Key concerns persist regarding the provision of 24-hour social and healthcare for the ageing population, slow progress on a proposed hospital unit, and the need for more purposeful activity.
PRISON
Key concerns
Dover (2022)
The Dover Independent Monitoring Board's 2021 report details critical issues at the Tug Haven, Kent Intake Unit (KIU), and Frontier House Short-Term Holding Facilities. While some initial improvements were noted in induction processes and staff interactions, the facilities were largely unsuitable for their purpose, particularly Tug Haven, which routinely held detainees overnight in overcrowded, unheated tents with inadequate sleeping, washing, and food provisions. Significant concerns were raised about poor hygiene, brief and ineffective medical screenings leading to undetected serious injuries, and excessive lengths of stay, causing distress and confusion among detainees, including vulnerable families and children.
PRISON
Key concerns
North Sea Camp (2024)
HMP North Sea Camp generally provides a safe and humane environment, with a strong emphasis on humane treatment and a wide range of release preparation programs. Positive developments include improved facilities management, a proactive safer community team, and good healthcare services that receive positive feedback from prisoners. Key concerns include persistent delays in offender management paperwork, the unresolved situation for IPP prisoners, and poor accommodation standards with no plans for replacement or conversion of dormitories. Additionally, issues with prisoner property transfers, lack of on-site end-of-life care, and difficulties for disabled prisoners accessing resettlement opportunities remain.
PRISON
Key concerns
Aylesbury (2024)
HMP Aylesbury, a Category C prison, completed its transformation from a YOI this year, adapting to an older population with improved but still sub-standard regime delivery. Significant efforts were made to enhance safety, reduce gang violence, and manage illicit items, though their incursion remains a serious problem. While staffing levels improved, staff inexperience and a lack of purposeful activity remain key challenges impacting prisoner wellbeing, progression, and resettlement, as evidenced by long waiting times for healthcare and inadequate release preparation.
PRISON
Key concerns
North Sea Camp (2025)
HMP North Sea Camp is a Category D open prison providing a safe and humane environment with a new Governor making positive regime and community engagement changes. While healthcare and education services receive commendations, significant concerns persist around inadequate accommodation standards, particularly for double rooms and dormitories, and the lack of on-site residential healthcare for complex needs. The Board also highlights issues with delayed Offender Assessment System (OASys) completion by Community Offender Managers and the ongoing lack of progress for IPP prisoners.
PRISON
Key concerns
Glasgow, Edinburgh and Larne House Short Term Holding Facilities (2020)
This report covers the Glasgow, Edinburgh and Larne House Short-Term Holding Facilities from February 2019 to January 2020. The Board found that detainees are largely treated humanely and respectfully by DCOs across all establishments, noting good practice in various areas. However, significant concerns remain regarding the adequacy of airport Holding Rooms for longer stays, including lack of fresh air, natural light, showering facilities, and exercise opportunities. Other key issues include delays in building work at Glasgow Airport, inadequate separation of female accommodation at Larne House, and problems with accessing prescribed medication for detainees.
PRISON
Key concerns
Downview (2020)
HMP/YOI Downview is considered a safe and humane prison where healthcare needs are largely met. However, the Board identified significant challenges including an unsatisfactory induction process, unsuitable long-term segregation for complex cases, and persistent issues with London weighting affecting staff recruitment. Key working remains unimplemented, and both purposeful activity and resettlement efforts are hampered by short sentences and difficulties accessing performance data from service providers like Weston College and the CRC.
PRISON
Key concerns
East Sutton Park (2020)
HMP East Sutton Park maintained a safe and supportive environment for women prisoners amidst the COVID-19 pandemic, successfully adapting education and family contact. However, significant concerns remain regarding the insufficient time prisoners have to benefit from resettlement, inconsistent transfers from closed establishments, and pandemic-induced disruptions to sentence planning. Staffing issues in key areas and challenges with dental provision and enabling internet access for distance learning were also highlighted.
PRISON
Key concerns
Eastwood Park (2020)
This IMB annual report for HMP/YOI Eastwood Park for the year ending October 2020 highlights the significant impact of the COVID-19 pandemic on prison operations and monitoring. While staff efforts and communication were generally commendable, concerns persist regarding rising self-harm incidents, ongoing violence towards staff, and the continuous flow of illicit substances. The Board remains particularly concerned about the prolonged segregation of a brain-injured prisoner and the lack of appropriate secure specialist facilities for women with complex needs.
PRISON
Key concerns
Durham (2020)
HMP Durham transitioned to a reception and resettlement prison for adult males and young offenders in February 2020. The reporting year was significantly impacted by COVID-19, leading to a restricted regime for much of the period. The Board noted positive developments in first night inductions, a reduction in self-harm, and improved healthcare provision by a new contractor. However, persistent concerns include overcrowding, low levels of key workers and Listeners, and the prolonged detention of immigration detainees. The report also highlights challenges with access to purposeful activity for specific prisoner groups and staffing consistency in healthcare.
PRISON
Key concerns
Gatwick pre-departure accommodation (2020)
The reporting year 2020 was exceptional due to the COVID-19 pandemic, leading to the Gatwick Pre-departure Accommodation (PDA) being largely closed from March onwards. Only three families were held between January and March, none of whom were removed from the UK; all were released back into the community. Consequently, the Independent Monitoring Board's annual report for this period is necessarily limited in its scope and findings.
PRISON
Key concerns
Full Sutton (2020)
HMP Full Sutton's IMB report for 2020 highlights the extensive impact of the COVID-19 pandemic on the prison's operations, with significant regime restrictions in place. Despite these challenges, the prison successfully maintained safety, experienced reductions in self-harm and assaults, and generally treated prisoners humanely. However, opportunities for purposeful activity, education, and progression were severely curtailed, and previous recommendations on these issues remain unaddressed due to the pandemic.
PRISON
Key concerns
Brook House (2020)
In 2020, Brook House IRC faced significant challenges due to the COVID-19 pandemic, a contract change to Serco, and a compressed charter flight programme for Dublin Convention removals. The Board found the centre unsafe for vulnerable detainees in the latter months, marked by a dramatic increase in self-harm and suicidal ideation, and inhumane treatment of detainees due to Home Office policies. Delays in Rule 35 assessments, inadequate inductions, and issues with property and communication from the Home Office were key concerns, despite a welcome increase in staff numbers and some improvements in facilities.
PRISON
Key concerns
Exeter (2020)
This report presents the findings of the Independent Monitoring Board at HMP Exeter for the year 2020. The prison managed the COVID-19 pandemic well, with a settled atmosphere and low virus transmission, despite severe restrictions curtailing regime activities. While staff provided humane treatment and healthcare met community standards, significant concerns persist regarding the inadequate provision for prisoners with serious mental health issues, challenges in staff recruitment and retention, and the limited opportunities for education and resettlement due to the restricted regime.
PRISON
Key concerns
Dungavel House IRC (2020)
Dungavel House IRC successfully managed its operations during the 2020 COVID-19 pandemic, with no detainee infections and staff commended for their resilience. Detainees report feeling safe, benefiting from good healthcare, a relaxed regime, and improved escort services. However, concerns persist regarding the length of detention, roof access, staff training, parking, and gate upgrades.
IRC
Key concerns
Swaleside (2021)
HMP Swaleside experienced a challenging year due to COVID-19, but management and staff were commended for their exceptional response and innovative strategies. The prison maintained a positive trajectory with declining violence and improved humane treatment, though concerns persist regarding resettlement provision and the mental health impact of prolonged lockdown. Key issues include kitchen capacity, access to confidential complaints, and disparities in opportunities for vulnerable groups.
PRISON
Key concerns
North West and Midlands STHF (2024)
This IMB report for Short-Term Holding Facilities (STHFs) highlights an increase in both Board membership and visits, alongside a rise in the number of people detained during 2023. Key concerns include significant safety risks for female detainees at Manchester RSTHF due to co-location with male Foreign National Offenders and a general lack of essential provisions like hot food, CCTV, and prompt access to prescribed medication in other facilities. The report also notes delays in addressing maintenance issues and reliance on external emergency services for medical needs.
PRISON
Key concerns
Rye Hill (2025)
HMP Rye Hill, a privately run Category C training prison for men convicted of sexual offences, successfully managed a significant expansion and recategorisation during the reporting year. The prison saw a considerable reduction in violence, self-harm, and use of force, alongside an 'outstanding' CQC rating for its healthcare provision. Key concerns persist regarding the ongoing injustice of IPP sentences, the complexities of the compassionate release process, and issues with prisoner property and hospital escort availability.
PRISON
Key concerns
Erlestoke (2025)
HMP Erlestoke is a Category C training and resettlement prison with an operational capacity of 512. The Board observed improvements in healthcare attendance and use of force scrutiny, alongside a decrease in staff turnover. However, significant concerns remain regarding the deteriorating healthcare building, the pervasive availability of illicit substances, and the inadequate provision for vulnerable prisoners, including the elderly and those requiring essential medication on transfer.
PRISON
Key concerns
Channings Wood (2025)
HMP Channings Wood, a Category C prison, experienced an increase in deaths in custody and persistent issues with prisoner property and outstanding infrastructure repairs during the reporting period ending August 2025. Despite improvements in education attendance and some aspects of daily regime, concerns remain regarding out-of-hours healthcare for an ageing population, insufficient purposeful activity, and the negative impact of staffing reductions on key services. The Board highlights the inhumane conditions for IPP prisoners and notes a significant rise in prisoner complaints.
PRISON
Key concerns
Leyhill (2020)
HMP Leyhill, a Category D open prison, has demonstrated strong performance driven by a new community-focused dynamic, leading to improvements in facilities and resident engagement. However, the Board highlights persistent issues including significant delays in ablution refurbishment, the slow progression of IPP sentences, and insufficient approved premises hindering Release on Temporary Licence. Concerns also remain regarding night-time staffing levels and the recurring problem of lost prisoner property during transfers.
PRISON
Key concerns
Lincoln (2020)
HMP Lincoln, a Category B local prison, generally treats prisoners fairly and humanely, with a predictable regime and improved cleanliness, according to the IMB's report for 2019-2020. Key improvements include reduced violence, better staff-prisoner relationships, and improved healthcare and education provision. However, significant concerns persist regarding the high level of self-harm, prisoner homelessness on release, and ongoing maintenance issues affecting accessibility and facilities.
PRISON
Key concerns
Low Newton (2020)
HMP/YOI Low Newton provides a generally safe and humane environment with high staff morale and respectful interactions. Healthcare provision is good for most, but the Board highlights long-standing concerns regarding the detention of mentally ill women due to a lack of community places and delays in hospital transfers. Deteriorating prison infrastructure, particularly leaky roofs, significantly impedes education and work opportunities. Resettlement efforts are hampered by a lack of suitable accommodation for a notable proportion of releases. The Board also raised concerns about drug misuse (Buscopan) and the need for more funding for key support services.
PRISON
Key concerns
North Sea Camp (2020)
HMP North Sea Camp is an open Category D prison noted for its rehabilitative culture and generally humane treatment of residents. The Board commends improvements in healthcare and positive staff-resident relationships, alongside community engagement. However, significant concerns remain regarding delays in Offender Management paperwork, inadequate accommodation conditions (including continued use of dormitories), and a lack of specific facilities for end-of-life and dementia care for the prison's increasing elderly population. These issues, alongside property transfer problems and laundry machinery breakdowns, require urgent attention and capital investment.
PRISON
Key concerns
Lowdham Grange (2020)
HMP Lowdham Grange generally provides fair and humane treatment, evidenced by a positive regime and improved staffing stability. Violence has decreased, and healthcare provision is seeing significant improvements, although challenges remain with mental health transfers and inadequate accommodation. Concerns persist regarding property loss, the consistency of the key worker scheme, and slow progress for IPP prisoners, along with ongoing issues in education and access to local prisons for release planning.
PRISON
Key concerns
Hull (2020)
HMP Hull, a category B local and YOI prison, recorded 8 deaths in custody this year, including four self-inflicted, but generally maintained a safe environment with reductions in violence and substance misuse incidents. While healthcare provision and purposeful activity are largely positive, the Board identified significant concerns including persistent problems with property management, delays in mental health transfers, slow contractor responses to maintenance, and a lack of post-release outcome data. Recommendations address these issues, aiming to improve prisoner experience, particularly for vulnerable individuals and young adults.
PRISON
Key concerns
Moorland (2020)
HMP/YOI Moorland, a Category C male resettlement prison, has reported significant improvements in safety metrics, including reductions in violence, self-harm, and drug use during the March 2019 – February 2020 reporting period. The Board noted positive developments in staff-prisoner relationships and the IEP system. However, national shortages in secure mental health beds, limited offending behaviour programmes, and a persistent lack of suitable accommodation for released prisoners remain key concerns.
PRISON
Key concerns
Nottingham (2020)
HMP Nottingham saw overall improvements in fairness and safety during the reporting year, including a reduction in violence against staff and deaths in custody. However, self-harm incidents rose significantly, and concerns persist regarding long delays for mental health transfers and the high number of prisoners released without accommodation. The Board also highlighted issues with purposeful activity uptake and the key worker scheme's inconsistent implementation.
PRISON
Key concerns
New Hall (2020)
HMP/YOI New Hall received a generally positive assessment from the IMB for the reporting year ending February 2020, with prisoners treated fairly and humanely. The report highlighted improvements such as reduced self-harm, the introduction of in-cell telephony, and an outstanding education success rate of 96.69%. Key concerns, however, included long waits for mental health transfers, insufficient staffing and resources for vulnerable prisoners, and persistent issues with property transfer and resettlement accommodation.
PRISON
Key concerns
Drake Hall (2020)
Drake Hall continues to provide a safe and humane environment, with staff and prisoners adapting well to the challenges of the COVID-19 pandemic, maintaining good order and low levels of violence. However, long-standing concerns persist regarding the unfit condition of Richmond and Plymouth houses, and systemic issues with prisoner property transfers. The pandemic's restricted regime has impacted rehabilitation and purposeful activity, raising concerns about the mental health and resettlement prospects of prisoners, especially those shielding.
PRISON
Key concerns
Hindley (2020)
The reporting year was largely dominated by the COVID-19 pandemic, leading to significant regime restrictions. Despite these challenges, the Board found HMP/YOI Hindley to be a generally safe and humane environment, commending staff efforts in managing the pandemic and maintaining positive staff-prisoner relationships. Key concerns remain around the cramped and unfit accommodation, the consistency of resettlement support, and the increased availability of illicit substances.
PRISON
Key concerns
Littlehey (2020)
HMP Littlehey remains a safe, fair, and decent Category C training prison for men convicted of sexual offenses, despite facing significant challenges. Key issues include persistent overcrowding, ongoing structural and heating problems, and inadequate provision for older prisoners and those with mental health needs, often leading to inappropriate CSU placements. The Board notes improvements in social care and equality monitoring, but highlights concerns regarding regime curtailments for staff training, slow responses to property complaints, and a backlog in offender management.
PRISON
Key concerns
Humber (2020)
HMP Humber faced significant challenges in 2020, operating under severe COVID-19 restrictions for nine months. The Governor and staff were highly commended for their professionalism in maintaining safety and minimizing virus spread. However, the Board expressed grave concerns about the long-term impact of extended lock-up on prisoner mental health, progression, and purposeful activity, while persistent issues like property loss and PALS response delays remained problematic.
PRISON
Key concerns
Isis (2020)
HMP/YOI Isis operated under a severely restricted regime throughout most of 2020 due to the COVID-19 pandemic, leading to prisoners spending up to 23.5 hours a day in their cells and limited access to education, work, and association. The Board commended the prison leadership for managing these challenges and highlighted improvements in hygiene, but raised significant concerns about the impact of the regime on prisoner well-being, the ongoing issue of housing prisoners with chronic mental health needs in an unsuitable environment, and persistent problems with staff recruitment and property transfers. Despite a drop in overall violence during lockdown, levels began to rise towards the year's end, particularly among young adults.
PRISON
Key concerns
Huntercombe (2020)
HMP Huntercombe, a Category C prison for foreign national men, successfully managed the COVID-19 pandemic despite significant regime restrictions, with no deaths in custody and positive commendations for its healthcare team. The Board identified several areas for development, notably the unfairness of telephone charges and lack of in-cell telephony, and the concerning increase in time-served prisoners held under immigration powers. Issues surrounding meaningful vocational training and progression to open conditions for foreign national prisoners were also highlighted as key areas needing attention.
PRISON
Key concerns
IMB Recommendations (40)
Heathrow Immigration Removal Centre (2020)
The Home Office and DET should provide greater guidance for detainees returning to a country where they have not lived for some time, ensuring that they are better equipped for their return.
Home Office
Bedford (2023)
The early identification of release areas by the probation service would be helpful where prisoners, because of the length of time served on remand, have only a week or so before release – better coordination in this area would be really useful.
HMPPS
Bristol (2024)
There appears to be insufficient support for prisoners on release to prevent them returning to prison for short periods of time and/or being recalled due to relatively minor licence breaches. How will the Minister address this?
Ministry of Justice
Ashfield (2024)
In common with other prisons, a small number of prisoners released from Ashfield in the last 12 months did not have suitable accommodation arranged prior to release. What solution is the Minister proposing to resolve this matter?
Ministry of Justice
Ranby (2020)
Will the minister explain why 36% of prisoners are released with no fixed abode, and why for the same reason prisoners suitable for home release are not being allowed out of HMP Ranby?
Ministry of Justice
Leyhill (2020)
In view of the unfairness (and potential for discouragement) created when a lack of spaces in approved premises leads to delay in release on temporary licence (ROTL) and thus the potential timing of release (see paragraph 11.1), what action will the minister take to remedy this situation as a matter of urgency?
Ministry of Justice
Hindley (2020)
The Board understands the challenges which the COVID-19 pandemic has caused but is concerned about the consistency and availability of the information, advice and guidance provided for prisoners released from HMP/YOI Hindley.
Governor / Director
Leicester (2021)
Does the minister agree that assisting them to make progress to safe discharge should have a higher priority?
Ministry of Justice
Stoke Heath (2023)
Can the process for prisoners to rejoin their community upon release be reviewed, to ensure all prisoners are offered accommodation upon release?
HMPPS
Send (2023)
The shortage of probation officers, both at Send – where four of the six full-time equivalent probation officer posts are currently vacant – and in the community, has had a damaging effect on prisoners’ progression and prospects for successful reintegration into society.
HMPPS
Rye Hill (2023)
The Board remains concerned that the movements from Category B to Category C and then to Category D prisons represent a particular problem for prisoners convicted of sexual offences and with the increasing number of direct releases (54 this year against only 20 in 2019/2020 reporting year) frequently leaves them being released with no specialist support.
HMPPS
Altcourse (2023)
How will the resettlement needs of remand prisoners be addressed, given the lack of provision for this in the current contract?
HMPPS
Altcourse (2023)
What efforts are being made to address the failure of Seetec to deliver on their contract responsibility to deliver a service that supports individuals to find suitable accommodation on release?
HMPPS
Swaleside (2025)
The Board remains concerned that prisoners are being released from Swaleside without proper support. How does the Governor plan to address this issue?
Governor / Director
East Sutton Park (2025)
Could the prison develop comprehensive guidance for prisoners preparing for reintegration into the community, outlining the required steps and associated responsibilities to be completed prior to release, as well as identifying the appropriate contacts for assistance? The Board recommends establishing an orderly role to support prisoners nearing release.
Governor / Director
Doncaster (2025)
The Board remains concerned about the high number of prisoners being released with no fixed abode? What steps will the Minister take to work with the relevant government departments to develop and implement a coordinated plan to address this serious issue?
Other
Yarl’s Wood (2020)
The Board recommends that upon the release of STHF detainees, their destination addresses are confirmed as a matter of urgency to enable medical records to be forwarded swiftly to their GPs, so allowing access to essential medical care.
Home Office
Usk and Prescoed (2020)
The Board notes that sometimes prisoner records are very slow in reaching the open estate. Assessment records which are locked or unavailable to the receiving establishment cause delay in the smooth transition of prisoners, on a fourfold basis: 1. in terms of liaison with statutory agencies 2. the assessment of risk 3. planning for ROTL and eventual release into the …
HMPPS
Swaleside (2024)
New prisoners are not receiving adequate induction and the Board is very concerned that prisoners are being released from Swaleside without proper support.
Governor / Director
Portland (2024)
In the Board’s view, the early release scheme (ERS) has been poorly thought through and rolled out, relying on the offender management unit (OMU) to fill the gaps in the resettlement process without the staffing increase to accommodate the extra work. This has had an adverse effect on the quality of the service provided and means that prisoners are not …
HMPPS
The Mount (2025)
HMPPS should take more action to support IPP prisoners, both leading up to and following release into the community.
HMPPS
Bronzefield (2020)
The government’s early release and special licence schemes have failed, in large part, owing to the requirement to tag a prisoner to an address. What is the government proposing to do to address this issue while lockdown restrictions continue?
Ministry of Justice
Winchester (2023)
What support can be provided to help remand prisoners with release planning as they are not eligible for probation services?
Ministry of Justice
Wetherby (2023)
Too many young people continue to be placed further than 50 miles from their home, thus reducing the potential to support family links. Is there anything that can be done to change this?
HMPPS
Preston (2023)
To provide more family engagement in preparation for prisoner’s release.
Governor / Director
Portland (2023)
Need for inter-departmental communication relating to prisoners’ pathways to resettlement
Governor / Director
Moorland (2023)
Can there be a general improvement in sentence progression and resettlement services for prisoners?
Governor / Director
Littlehey (2023)
The Board is concerned that prisoners have been transferred to HMP Littlehey, which does not have a 24-hour healthcare facility, when they were already very unwell. Although the Board recognises that HMP Littlehey provides excellent end of life care, it is concerned that such transfers could be detrimental to the transferring prisoner. The Board would like to understand the criteria …
HMPPS
Heathrow immigration removal centre (2023)
The Home Office has a duty of care for those with mental health problems and to ensure that they are safe in the community they are released into. Robust support is required for detained people with mental health people who are released on bail.
Ministry of Justice
Downview (2023)
delivery of the contracted family engagement resource.
Governor / Director
Dartmoor (2023)
The HMPPS’s Ageing Population Strategy was due to be published this year. Given the high proportion of older prisoners in HMP Dartmoor, when will this Strategy be published and when will initiatives to help older prisoners be announced?
HMPPS
Winchester (2024)
What can be done to support and reduce the high number of men on remand who are released immediately from court on bail, licence or as time served?
Ministry of Justice
Channings Wood (2024)
Year after year, we have been told that the ageing population strategy is coming soon. As in our previous report, the Board asks, again, when will it arrive and what improvements will it bring to the living conditions and care needs of elderly prisoners?
Ministry of Justice
Portland (2020)
Checks need to be put in place to ensure that critically unwell prisoners, suffering significant health problems, cannot be unilaterally transferred. Should this ever be necessary, it should not happen without prior negotiation with the receiving establishment and the provision of up to date and comprehensive medical records.
HMPPS
Heathrow Immigration Removal Centre (2021)
C&C should consider working more closely with the healthcare provider to maximise the value of the care suite for respite care for vulnerable detainees.
Governor / Director
Maidstone (2023)
Provide feedback to HMP Maidstone on the effectiveness of activities undertaken to prepare prisoners for release both in the UK and abroad.
HMPPS
Bedford (2023)
Prisoners need to attend the pre-release board and we hope that the prison can facilitate this.
Governor / Director
The Mount (2025)
HMPPS should consider prohibiting the transfer of a prisoner from one establishment to another within, say, three months of their release date unless there is a particular reason for doing so, such as to be nearer to their family.
HMPPS
Maidstone (2023)
Give permission to HMP Maidstone to offer a release on temporary licence.
HMPPS
Leyhill (2023)
What steps will be taken to speed up the work and enhance the efficiency of the community offender managers (COMs) in the external probation service?
HMPPS
PHSO Casework Decisions (288)
P-003080 — Norfolk and Norwich University Hospitals NHS Foundation Trust
Mr A says the Trust discharged his wife from hospital in June 2023 when she was not fit to do so and without putting a care and support package in place.
NHS in England
Oct 2024
P-003301 — Malling Health
Mrs S complains the organisation did not take appropriate action when her father did not answer its calls to monitor his COVID-19 infection. She says it should not have discharged him.
NHS in England
Upheld
Jan 2025
P-003303 — Manchester University NHS Foundation Trust
Mr G says the Trust failed to carry out appropriate assessments before discharging his father from hospital in December 2022 and because of this, his father was readmitted two hours later.
NHS in England
Jan 2025
P-003611 — East Kent Hospitals University NHS Foundation Trust
Mrs A complains the Trust discharged her from hospital too soon after surgery to remove the right half of the colon.
NHS in England
Jun 2025
P-004690 — University Hospitals Birmingham NHS Foundation Trust
Mrs A complains about the care and treatment her late mother, Mrs L, received from a hospital in Birmingham between July and August 2023. She says her mother was injured due to being placed on a faulty chair and that her discharge care package failed.
NHS in England
Jan 2026
P-001089 — Royal United Hospitals Bath NHS Foundation Trust
Miss N complains that the Trust unsafely discharged her mother from hospital.
NHS in England
Upheld
Jun 2021
P-001094 — The Royal Bournemouth and Christchurch Hospitals NHS Foundation …
Mrs U complains that the Trust did not provide sufficient care for her late father’s continence issues and inappropriately discharged him. She also complains that the Trust did not tell the care home that her father needed an extended bed and suitable armchair.
NHS in England
Not Upheld
Aug 2021
P-001229 — University Hospitals Birmingham NHS Foundation Trust
Mr L complains about the way doctors discharged his father from hospital in February 2020. He also says the discharge documentation was not detailed enough.
NHS in England
Dec 2021
P-001233 — Buckinghamshire Healthcare NHS Trust
Ms T complains about aspects of the care provided to her partner, Mr S, at the Trust. Ms T also complains about a lack of communication with her, and a lack of compassion in the end of life care for Mr S.
NHS in England
Upheld
Dec 2021
P-001293 — United Lincolnshire Hospitals NHS Trust
Ms A complained about her terminally ill client, Mr H, not being offered a place in a hospice after being discharged from hospital, and instead being allowed to go home with no support in place.
NHS in England
Feb 2022
P-001379 — County Durham and Darlington NHS Foundation Trust
Mr G complained that staff at the County Durham and Darlington NHS Foundation Trust left him unattended for long periods of time when he was an inpatient. He also says that they failed to remove a cannula from his arm when he was discharged, and did not send details of …
NHS in England
Apr 2022
P-001468 — The Dudley Group NHS Foundation Trust
Miss K complains about the care and treatment provided to her mother by the Trust during two admissions in May 2020. She complains the Trust incorrectly discharged her mother, discharged her into the wrong residential care setting, and failed to provide adequate physiotherapy care.
NHS in England
Not Upheld
Jul 2022
P-001454 — Barnsley Hospital NHS Foundation Trust
Mrs E complains that hospital staff did not properly account for her husband’s dementia when caring for him during his admission. Mrs E says the Trust decided Mr E was ready to be discharged despite not having the right care in place, and told her that Mr E was ready …
NHS in England
Not Upheld
Jul 2022
P-001607 — Hull University Teaching Hospitals NHS Trust
Ms T complains Hull University Teaching Hospitals NHS Trust discharged her mother, Mrs K, without a care plan and did not tell the GP or social services about the discharge.
NHS in England
Nov 2022
P-001670 — Sheffield Teaching Hospital NHS Foundation Trust
Mr R complains the Trust’s discharge arrangements for his mother were premature and not put in place correctly. He says the Trust did not discharge her with a discharge summary or medication notes, and left her to use a pad rather than being taken to the toilet.
NHS in England
Dec 2022
P-001660 — Northern Care Alliance NHS Foundation
Miss H complains about the care the Trust gave to her mother between 8 June and 9 July 2021, when she had COVID-19 and symptoms of diarrhoea and vomiting. Miss H complains about her mother's basic care, the communication, the discharge decision and planning.
NHS in England
Dec 2022
P-001680 — Gateshead Health NHS Foundation Trust
Mrs T complains about her mother's inpatient stay at the Trust from 21 January to her discharge on 29 January 2021. She complains about poor communication, errors during discharge and errors in the do not attempt cardiopulmonary resuscitation (DNACPR) in place. She also complains the Trust has not learned from …
NHS in England
Dec 2022
P-001750 — East Suffolk and North Essex NHS Foundation Trust
Mrs C complains the Trust did not include her father's manual handling or exercise needs in the discharge summary or care plan it sent to the home when he was discharged.
NHS in England
Partly Upheld
Jan 2023
P-002013 — Bedfordshire Hospitals NHS Foundation Trust
Mrs C complains the Trust discharged her father too soon as he was dehydrated and could not move. She also complains it did not communicate her father's needs when he was discharged, meaning they did not know how best to care for him or keep him comfortable. She says because …
NHS in England
Partly Upheld
Jun 2023
P-003877 — Nottingham University Hospitals NHS Trust
Ms T complains the Trust would not let the family support her mother in hospital and it did not have a coordinated care plan. She says the Trust did not meet her mother’s individual needs and would not let her be discharged to the care of the family.
NHS in England
Partly Upheld
Jul 2023
P-002274 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss B complains about the standard of care the Trust gave to her father. She says the Trust made a mistake by discharging him back to the care home while he was still bleeding badly.
NHS in England
Oct 2023
P-002252 — Royal Cornwall Hospitals NHS Trust
Mr D complains the Trust discharged his wife in December 2022 after incorrectly telling her she did not have a fracture.
NHS in England
Oct 2023
P-002377 — Barts Health NHS Trust
Mr E complains about the care and treatment his mother had. He complains about her treatment, discharge and arranged care package that could not meet her needs.
NHS in England
Dec 2023
P-002466 — University Hospitals Birmingham NHS Foundation Trust
Mrs R complains about the care and treatment the Trust gave to her grandmother in March and April 2022, in respect of her hygiene needs, discharge planning, oxygen therapy and capacity to consent.
NHS in England
Upheld
Feb 2024
P-003682 — Warrington and Halton Hospitals NHS Foundation Trust
Mrs R says the Trust failed to ensure it safely handed over care and management of Mr R’s gallbladder drain to the district nursing team from another local trust in March 2021.
NHS in England
Partly Upheld
Aug 2024
P-002965 — The Rotherham NHS Foundation Trust
Miss G and Mr G complain about how the Trust cared for their mother. They complain about the medication it gave her, that she was discharged when she was still unwell, about the communication with the family and that her mother caught COVID-19 despite being in a side ward.
NHS in England
Partly Upheld
Sep 2024
P-003084 — Sheffield Teaching Hospitals NHS Foundation Trust
Ms N complains the Trust discharged her brother, who was autistic and non verbal, from hospital before his infection had cleared and without suitable provision for his care.
NHS in England
Oct 2024
P-003169 — Leicestershire Partnership NHS Trust
Mr K complains the University Hospitals of Leicester NHS Trust missed opportunities to diagnose his father with heart failure. Mr K also complains Leicestershire Partnership NHS Trust wrongly discharged his father.
NHS in England
Nov 2024
P-003297 — Royal Devon University Healthcare NHS Foundation Trust
Mrs E complains the Trust did not give her information about her son’s condition, discharged him when he was not well enough and failed to arrange follow up care.
NHS in England
Partly Upheld
Jan 2025
P-003295 — South Tyneside and Sunderland NHS Foundation Trust
Miss U complains the Trust did not provide her mother with adequate hydration in October 2021. Miss U also complains the Trust did not communicate with her regarding its Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision.
NHS in England
Upheld
Jan 2025
P-003316 — Herefordshire and Worcestershire Health and Care NHS Trust
Mr and Mrs D complain about the care the Trusts gave to their father in January and February 2022. They say he was discharged without appropriate care and support being arranged.
NHS in England
Partly Upheld
Feb 2025
P-003349 — Mid and South Essex NHS Foundation Trust
Mrs I complains about the Trust's care and treatment of her husband in August and September 2022. She says staff did not provide adequate nutrition and hydration, they did not make sure he participated in physiotherapy and they discharged him when he was not ready.
NHS in England
Partly Upheld
Feb 2025
P-003587 — Royal Cornwall Hospitals NHS Trust
Mrs B complains the Trust discharged her husband even though he had a fever and temperature and was unable to swallow the medication prescribed. She also says no discharge summary was completed.
NHS in England
Jun 2025
P-003598 — Gloucestershire Health and Care NHS Foundation Trust
Mrs N complains the organisations inappropriately discharged her father and failed to provide the right level of care when he was at home without regular visits.
NHS in England
Jun 2025
P-003600 — Rotherham, Doncaster and South Humber NHS Foundation Trust
Mr A complains the Trust has wrongly discharged him from its services following an appointment on 16 October 2023 and it will not provide him with any care or treatment for his psychological health.
NHS in England
Jun 2025
P-003679 — University Hospitals of North Midlands NHS Trust
Mrs A complains the Trust should have put her father on end-of-life care and did not discharge her father correctly in January 2023. She complains the Trust did not communicate well with the family, particularly around her father being discharged.
NHS in England
Upheld
Jul 2025
P-003729 — Portsmouth Hospitals University NHS Trust
Mr O complains about the inpatient care his wife received from the Trust from May to July 2021. This included premature discharge, inappropriate medication management and poor record keeping.
NHS in England
Upheld
Jul 2025
P-003701 — University Hospitals Sussex NHS Foundation Trust
Mrs N complains the Trust wrongly discharged her husband from A&E in April 2022 and then a month later, it diagnosed him with angina but did not provide any treatment. She also complains it did not arrange for an urgent X-ray.
NHS in England
Jul 2025
P-003801 — Central and North West London NHS Foundation Trust
Mr W complains the Trust discharged his mother when it was unsafe to do so, and did not appropriately manage a choking incident.
NHS in England
Aug 2025
P-003816 — South Warwickshire University NHS Foundation Trust
Mrs K complains about the Trusts care and treatment of her father in July and August 2024. She complains about the decision to discharge him without treating his jaundice, poor communication with the family and poor nursing care.
NHS in England
Aug 2025
P-003942 — Oxford University Hospitals NHS Foundation Trust
Ms T complains about care Mr R received at a hospital between March 2020 and December 2020. She complains the Trust did not offer appropriate treatment for Mr R’s prostate cancer, did not provide physiotherapy treatment and communicated poorly about a significant diagnosis.
NHS in England
Upheld
Sep 2025
P-004034 — Isle of Wight NHS Trust
Mrs F complains about the care and treatment Isle of Wight NHS Trust provided to her father, Mr P, during an inpatient admission from 11 December 2022 to 25 December 2022. Mrs F specifically complains about the Trust’s decision to move her father from the Intensive Care Unit, how he …
NHS in England
Sep 2025
P-003963 — Ashford and St Peter's Hospitals NHS Foundation Trust
Mrs G complains that Ashford and St Peter's Hospitals NHS Foundation Trust did not provide appropriate care, treatment, and monitoring to her mother during her admission following a cardiac arrest in the community.
NHS in England
Partly Upheld
Sep 2025
P-004033 — Kettering General Hospital NHS Foundation Trust
Mr L complained about the care Kettering General Hospital NHS Foundation Trust provided to his late father, Mr Y during a hospital admission. He complained about various aspects of care including fluid and nutritional care, care of a pressure sore, pain relief, and infection prevention control.
NHS in England
Partly Upheld
Sep 2025
P-003999 — East Kent Hospitals University NHS Foundation Trust
Mrs E complains about the care and treatment her father, Mr D, received from the Trust in April 2020. She says the Trust failed to diagnose and treat him appropriately after surgery, mismanaged his sepsis, overlooked signs of blood clots, and did not refer his case to the coroner despite …
NHS in England
Sep 2025
P-004086 — University Hospitals Sussex NHS Foundation Trust
Mrs U complains about the care and treatment the Trust provided to her husband from December 2021 to January 2022. She says during her husband's hospital admission, the Trust failed to appropriately manage his ongoing conditions and communication was poor.
NHS in England
Partly Upheld
Sep 2025
P-004240 — A practice in the Hastings area
The complainant says her father was placed on end-of-life care without being physically examined by a doctor. She says that if she hadn't intervened, he would've died prematurely as food, water and medication had been wrongly withdrawn.
NHS in England
Nov 2025
P-004439 — The Princess Alexandra Hospital NHS Trust
Mr P complains the Trust failed to provide appropriate bed care, investigations and treatment and pain medication to his late mother-in-law Mrs K. He also says the Trust unsafely discharged her when it realised it has inappropriately given her, end-of-life medications.
NHS in England
Dec 2025
P-004769 — Worcestershire Acute Hospitals NHS Trust
Mr B complains the Trust prematurely discharged his father, Mr K, in January 2024. He also complains it did not give him all the necessary information needed before he made the decision to withdraw treatment for his father in February 2024.
NHS in England
Feb 2026
P-004753 — Guy's and St Thomas' NHS Foundation Trust
An NHS Trust discharged a patient before they were medically fit, failed to carry out an occupational health assessment, did not make appropriate referrals, and sent them home despite limited mobility. The hospital also took seven months to respond to the complaint, exceeding given timescales without explanation.
NHS in England
Jan 2026
LGO / SPSO Decisions (455)
21-017-636 — London Borough of Hillingdon
Summary: We will not investigate Mr X’s complaint about the Council’s handling of a planning matter. This is because the complaint is late and the injustice Mr X claims is not the result of any fault by the Council.
LGO (Local Government & …
Planning
Mar 2022
21-018-433 — Kirklees Metropolitan Borough Council
Summary: We will not investigate this complaint about how the Council dealt with the complainant’s planning application. This is because the complainant had the right to appeal to the Planning Inspector.
LGO (Local Government & …
Planning
Mar 2022
21-013-691 — Buckinghamshire Council
Summary: Ms X complains about the Council’s failure to enforce a condition of a planning permission granted by the Planning Inspectorate. There was fault by the Council because of unreasonable delay in dealing with the matter. The Council agreed to act to remedy the injustice.
LGO (Local Government & …
Planning
Upheld
Mar 2022
21-012-644 — Bolton Metropolitan Borough Council
Summary: Mrs X complained about the Council’s decision to approve a large storage facility on land near her home, which she feels affects her amenities. There was some fault in the way the Council made its decision (which it had already agreed to remedy) but this did not cause a …
LGO (Local Government & …
Planning
Upheld
Mar 2022
21-004-337 — Kirklees Metropolitan Borough Council
Summary: Mrs D complains about planning advice provided by the Council. The Ombudsman has discontinued the investigation because there is not enough evidence of fault to warrant further investigation.
LGO (Local Government & …
Planning
Not Upheld
Mar 2022
20-014-193 — Calderdale Metropolitan Borough Council
Summary: Mr C complains about the Council’s response to his reports of breaches of planning control which he says allowed a harmful impact on his family’s residential amenity and led to him spending unnecessary time and trouble in trying to resolve the matter. We have found fault by the Council …
LGO (Local Government & …
Planning
Upheld
Mar 2022
21-018-503 — East Lindsey District Council
Summary: We will not investigate this complaint about how the Council dealt with a planning application. This is because we are unlikely to find fault. The complainant has also not been caused significant injustice as a result of the alleged fault.
LGO (Local Government & …
Planning
Mar 2022
23-014-300 — Hartlepool Borough Council
Summary: X complained about the Council’s failure to take ownership of land used as a car park under the terms of a legal agreement. X also complained that the evidence they had provided to the Council about anti-social behaviour had not been presented to members of a committee tasked with …
LGO (Local Government & …
Planning
Upheld
Jun 2024
24-020-114 — Isle of Wight Council
Summary: We cannot by law investigate this complaint about an alledged failure by the Council to provide information to the Planning Inspectorate for the purposes of an appeal. This is because we have no legal jurisdiction to investigate a complaint when an appeal has been made to the Planning Inspectorate, …
LGO (Local Government & …
Planning
Apr 2025
24-021-217 — Havant Borough Council
Summary: We will not investigate Mr X’s complaint about the Council’s handling of a planning enforcement matter. This is because there is not enough evidence of fault by the Council affecting its decision not to take formal enforcement action.
LGO (Local Government & …
Planning
May 2025
24-020-778 — Huntingdonshire District Council
Summary: We will not investigate this complaint about the Council’s decision not to take formal action regarding the condition of his neighbour’s land. There is not enough evidence of fault in the Council’s decision-making process to warrant us investigating.
LGO (Local Government & …
Planning
May 2025
25-004-016 — Blackburn with Darwen Council
Summary: We will not investigate this complaint about the way the Council decided the complainant’s planning application. He appealed to the Planning Inspector against the Council’s refusal. This complaint is therefore outside our jurisdiction.
LGO (Local Government & …
Planning
Aug 2025
25-003-488 — Nottinghamshire County Council
Summary: We will not investigate Mrs X’s complaint about the Council’s involvement as a flood risk consultee on a planning application she made to a different authority.
LGO (Local Government & …
Planning
Aug 2025
25-014-132 — Winchester City Council
Summary: We will not investigate this complaint about how the Council dealt with a planning application. This is because the complainant had the right to appeal to the Planning Inspector.
LGO (Local Government & …
Planning
Dec 2025
25-010-201 — North Northamptonshire Council
Summary: We will not investigate this complaint that the Council has refused to engage with complainant about finding a viable use for a listed building he owns. There is insufficient evidence of fault in the way the Council has responded to the request for engagement, and we cannot investigate alleged …
LGO (Local Government & …
Planning
Dec 2025
202302720 — Forth Valley NHS Board
C complained about their attendance at the A&E after their child (A) had a seizure. C said that A’s observations (to measure vital signs like heart rate, blood pressure, and temperature) had not been taken, but that the nurse had told C that they were. C also raised concerns about …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2025
NIPSO-17984 — Belfast Health and Social Care Trust
The Belfast Health and Social Care Trust has apologized to a patient who was forced to arrange her own care package after being discharged from the Royal Victoria Hospital, Belfast.
NIPSO (NI Public Service…
Health & Social Care
May 2019
NIPSO-20700 — Belfast Health and Social Care Trust
We found that the Belfast Health and Social Care Trust did not provide a patient with a multi-disciplinary review prior to her discharge from the Royal Victoria Hospital.
NIPSO (NI Public Service…
Health & Social Care
Feb 2021
PSOW-202500164 — Betsi Cadwaladr University Health Board
Ms A complained about the care and treatment provided to her father, by the Health Board, between November 2023 and September 2024 and that the response provided to her complaint did not address all of her concerns. The Ombudsman found that, although the Health Board had conducted an investigation into …
PSOW (Public Services Om…
Health
Aug 2025
21-014-981a — HCRG Care Group (21 014 981a)
Summary: We found the Council and HCRG Care Group failed to inform Mr C’s family that the care agency supporting him would be unable to do so on a long-term basis. This meant that, when the care agency withdrew care, Mr C’s family were given very little time to arrange …
LGO (Local Government & …
Health
Upheld
Jul 2022
21-014-334 — London Borough of Enfield
Summary: There was a delay in completing an occupational therapy assessment for Ms Y which caused avoidable inconvenience and frustration. The Council will apologise, make payments of £500 to Ms Y and £150 to Mr X for his avoidable time and trouble. It will also review procedures as described in …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
22-003-374 — Kent County Council
Summary: We will not investigate this complaint about the Council’s social worker provision. This is because there is insufficient evidence of a significant injustice to warrant investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-005-829a — Warrington & Halton Hospitals NHS Foundation Trust (21 …
Summary: Mrs B complains about what happened when her father, Mr C, was discharged from hospital after attending with a fractured collarbone, and about arrangements for putting a care package in place. We found the Trust was at fault for the lack of information given to Mr C and his …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-013-816b — Bromley Healthcare CIC Ltd (21 013 816b)
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. …
LGO (Local Government & …
Health
Not Upheld
Oct 2022
21-013-816a — Kings College Hospital NHS Foundation Trust (21 013 …
Summary: Mrs D complained about the way the Council, the Trust and Bromley Healthcare dealt with her late brother Mr S’s discharge from hospital, wheelchair provision and social care. We have not upheld the complaints about the Council and Bromley Healthcare. Most complaints about the Trust are also not upheld. …
LGO (Local Government & …
Health
Upheld
Oct 2022
22-003-473 — Surrey County Council
Summary: We will not investigate Mr B’s complaint about the Council’s failure to assess Ms C and charge her for her placement. This is because the Council has acknowledged its failings and remedied the fault.
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-008-070 — Essex County Council
Summary: Mr L complained about the way the Council supported his son, Mr X’s care needs. Mr L said the Council failed to meet Mr X’s care needs and failed to meet his, and his wife’s needs as carers. The Council delayed in assessing the care and support needs and …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-017-310 — Medway Council
Summary: The Council took too long to review Mr B’s financial assessment which allowed arrears to accrue. It also did not properly consider whether he could afford to pay the arrears. The Council has agreed to take the action recommended below.
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
20-011-643 — London Borough of Croydon
Summary: Miss X complains the Council has prolonged her stay in residential care, but the evidence shows the Council has made every time to enable a supported return home. Miss X has so far chosen not to pay for the renovations her house requires to be habitable.
LGO (Local Government & …
Adult Care Services
Not Upheld
Oct 2022
23-012-080 — Bournemouth, Christchurch and Poole Council
Summary: Mrs D complained the Council delayed assigning a social worker and completing an assessment of her daughter’s care and support needs. We find the Council was at fault for its delay in assigning a social worker and completing the assessment. The Council has agreed to make a payment to …
LGO (Local Government & …
Adult Care Services
Upheld
May 2024
23-011-466 — Lancashire County Council
Summary: Mrs A has complained about a hospital trust and a council in relation to her mother, Mrs B’s discharge to a care home and the fees her mother was charged. We found fault with the Council and the Trust in relation to the discharge a delay in moving Mrs …
LGO (Local Government & …
Adult Care Services
Upheld
Jul 2024
24-003-689 — New Forest National Park Authority
Summary: We will not investigate this complaint about the Authority’s handling of a planning application for development at a site close to Mr X’s home. This is because we are unlikely to find evidence of fault by the Authority or injustice caused to Mr X sufficient to warrant an investigation.
LGO (Local Government & …
Planning
Jul 2024
24-004-957 — East Devon District Council
Summary: We will not investigate this complaint about the Council’s building control service. This is because we are unlikely to find fault.
LGO (Local Government & …
Planning
Jul 2024
24-004-524 — Derbyshire County Council
Summary: We will not investigate this complaint about the response the Council provided to a consultation request for a planning application. This is because we are unlikely to find fault.
LGO (Local Government & …
Planning
Jul 2024
23-016-286 — Folkestone & Hythe District Council
Summary: Mr D complains the Council delayed seeking compliance with a planning Enforcement Notice. We have not found evidence of fault by the Council and have completed the investigation and not upheld the complaint.
LGO (Local Government & …
Planning
Not Upheld
Jul 2024
23-016-127 — Staffordshire Moorlands District Council
Summary: Mrs X complained the Council has failed to take timely and appropriate action in relation to breaches of planning control at a site next to her home. She complained the new houses loom over and reduce the natural light and privacy to her home. The Council’s failure to properly …
LGO (Local Government & …
Planning
Upheld
Jul 2024
24-006-312 — City of Doncaster Council
Summary: We will not investigate Mr B’s complaint about the Council not taking planning enforcement action against his neighbour. This is because there is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Planning
Jul 2024
23-011-152a — Calderdale & Huddersfield NHS Foundation Trust (23 011 …
Summary: Ms D complains about faults by Calderdale Metropolitan Borough Council and Calderdale & Huddersfield NHS Foundation Trust in managing her mother, Mrs X’s, discharge from hospital. We have upheld Ms D’s complaints about assessing Mrs X’s ability to make her own decisions, consent and sharing information about community nursing …
LGO (Local Government & …
Health
Upheld
Aug 2024
24-000-008 — London Borough of Ealing
Summary: Mrs Y complained the Council failed to arrange suitable care for her mother, Mrs X, when she was discharged from hospital. Mrs Y said this meant she and her sister, Ms W, had to provide the care instead. The Council was at fault for delay in arranging a new …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2024
23-014-778a — Lewisham & Greenwich NHS Trust (23 014 778a)
Summary: We consider London Borough of Lewisham and Lewisham and Greenwich NHS Trust did not appropriately seek the views of Mrs Y’s supported accommodation before deciding she could not return there from hospital. Also, the Council did not carry out a Mental Capacity Act assessment and best interest decision in …
LGO (Local Government & …
Health
Upheld
Sep 2024
23-020-329 — London Borough of Enfield
Summary: We will not investigate this complaint about a lack of action on the complainant’s reports of breaches of planning control and building regulations. There is not enough evidence of fault in the Council’s actions to justify an investigation.
LGO (Local Government & …
Planning
Sep 2024
24-021-610 — London Borough of Sutton
Summary: We will not investigate this complaint about the way the Council decided to approve a planning application for a new property close to the complainant’s home. We have not seen enough evidence of fault in the decision-making process to justify an investigation. Also, we cannot achieve the outcome the …
LGO (Local Government & …
Planning
May 2025
24-013-233 — Herefordshire Council
Summary: Ms X complained the Council failed to take enforcement action over planning and licensing breaches from a neighbouring property. She said the breaches resulted in noise and anti-social behaviour, causing her distress. We found the Council took suitable steps to investigate Ms X’s complaints and was not at fault.
LGO (Local Government & …
Planning
Not Upheld
Jul 2025
24-015-474 — Torbay Council
Summary: Mr X complained the Council has not taken planning enforcement action to control a development near his home that does not have planning permission. He said the Council delayed its investigation until four years elapsed since the build, then said the work was immune from enforcement. Mr X said …
LGO (Local Government & …
Planning
Upheld
Aug 2025
25-006-223 — Bury Metropolitan Borough Council
Summary: We will not investigate Mr X’s complaint about the Council not taking action against a property developer. It is unlikely we would find fault.
LGO (Local Government & …
Planning
Aug 2025
24-019-452 — East Devon District Council
Summary: We will not investigate this complaint about planning advice as there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Planning
Sep 2025
25-007-008 — Runnymede Borough Council
Summary: We will not investigate this complaint about the Council refusing to take planning enforcement action against an outbuilding, which was not built in accordance with the approved plans. There is insufficient evidence of fault in the way the Council reached its decision on the enforcement case, and an investigation …
LGO (Local Government & …
Planning
Sep 2025
25-006-435 — Forest of Dean District Council
Summary: We will not investigate this complaint about the Council’s handling of planning matters at a site next to where the complainant lived. This is because: it is reasonable to expect the complainant to have contacted us sooner; there is insufficient evidence of fault; it is reasonable for the complainant …
LGO (Local Government & …
Planning
Sep 2025
25-005-033 — London Borough of Brent
Summary: We will not investigate this complaint about the conduct of a Council officer during a telephone call with the complainant. We consider there is no worthwhile outcome achievable by our investigation.
LGO (Local Government & …
Planning
Sep 2025
25-002-990 — London Borough of Southwark
Summary: We will not investigate this complaint about the Council providing incorrect planning advice in 2023. We have not seen enough evidence of fault in the Council’s actions to justify an investigation.
LGO (Local Government & …
Planning
Sep 2025